{ "hospital_name": "Northwestern Medicine Valley West Hospital", "last_updated_on": "2026-04-01", "version": "3.0.0", "location_name": [ "Northwestern Medicine Valley West Hospital" ], "hospital_address": [ "1302 N. Main Street, Sandwich, IL 60548" ], "license_information": { "license_number": "0004690", "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": [ "1184705931", "1316002520" ], "standard_charge_information": [ { "description": "1.5MM TI CORTEX SCREW SELF-TAPPING 6MM", "code_information": [ { "code": "SUP-49999", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 30.02, "maximum": 435.01, "setting": "outpatient", "gross_charge": 435.01, "discounted_cash": 304.51, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.02, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 483.01, "10th_percentile": 483.01, "90th_percentile": 483.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.02, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 483.01, "10th_percentile": 483.01, "90th_percentile": 483.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.02, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 483.01, "10th_percentile": 483.01, "90th_percentile": 483.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.02, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 483.01, "10th_percentile": 483.01, "90th_percentile": 483.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.02, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 483.01, "10th_percentile": 483.01, "90th_percentile": 483.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.02, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 483.01, "10th_percentile": 483.01, "90th_percentile": 483.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 82.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 82.65, "10th_percentile": 82.65, "90th_percentile": 82.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 82.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 82.65, "10th_percentile": 82.65, "90th_percentile": 82.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 82.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 82.65, "10th_percentile": 82.65, "90th_percentile": 82.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 274.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.06, "10th_percentile": 274.06, "90th_percentile": 274.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 355.4, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 355.4, "10th_percentile": 355.4, "90th_percentile": 355.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 283.41, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 283.41, "10th_percentile": 283.41, "90th_percentile": 283.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 243.17, "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": 243.17, "10th_percentile": 243.17, "90th_percentile": 243.17, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 262.75, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 262.75, "10th_percentile": 262.75, "90th_percentile": 262.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 262.75, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 262.75, "10th_percentile": 262.75, "90th_percentile": 262.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 435.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 435.01, "10th_percentile": 435.01, "90th_percentile": 435.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 435.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 435.01, "10th_percentile": 435.01, "90th_percentile": 435.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 110.49, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 941.82, "10th_percentile": 941.82, "90th_percentile": 941.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 284.5, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 284.5, "10th_percentile": 284.5, "90th_percentile": 284.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 151.38, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 151.38, "10th_percentile": 151.38, "90th_percentile": 151.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 301.46, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 301.46, "10th_percentile": 301.46, "90th_percentile": 301.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 291.02, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 291.02, "10th_percentile": 291.02, "90th_percentile": 291.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 218.38, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 218.38, "10th_percentile": 218.38, "90th_percentile": 218.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 435.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 435.01, "10th_percentile": 435.01, "90th_percentile": 435.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 197.06, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.06, "10th_percentile": 197.06, "90th_percentile": 197.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 355.4, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 355.4, "10th_percentile": 355.4, "90th_percentile": 355.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 283.41, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 283.41, "10th_percentile": 283.41, "90th_percentile": 283.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 210.11, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 210.11, "10th_percentile": 210.11, "90th_percentile": 210.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 380.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 380.63, "10th_percentile": 380.63, "90th_percentile": 380.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 369.76, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 369.76, "10th_percentile": 369.76, "90th_percentile": 369.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 326.26, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 326.26, "10th_percentile": 326.26, "90th_percentile": 326.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 348.01, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 348.01, "10th_percentile": 348.01, "90th_percentile": 348.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 195.75, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 195.75, "10th_percentile": 195.75, "90th_percentile": 195.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 293.2, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 293.2, "10th_percentile": 293.2, "90th_percentile": 293.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 236.43, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 236.43, "10th_percentile": 236.43, "90th_percentile": 236.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" } ] } ] }, { "description": "ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLN", "drug_information": { "unit": 10.15, "type": "ML" }, "code_information": [ { "code": "RX-181465", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "39328-0032-50", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.43, "maximum": 2.25, "setting": "outpatient", "gross_charge": 2.25, "discounted_cash": 1.57, "payers_information": [ { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1.01, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1.01, "10th_percentile": 1.01, "90th_percentile": 1.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1.97, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1.22, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.51, "10th_percentile": 1.51, "90th_percentile": 1.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.51, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.51, "10th_percentile": 1.51, "90th_percentile": 1.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.42, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.42, "10th_percentile": 1.42, "90th_percentile": 1.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.27, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.26, "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": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "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": "VWH BCBS PPO", "standard_charge_dollar": 1.83, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 0.78, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.57, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 0.57, "10th_percentile": 0.57, "90th_percentile": 0.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1.09, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 1.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1.91, "10th_percentile": 1.91, "90th_percentile": 1.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.83, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1.52, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1.52, "10th_percentile": 1.52, "90th_percentile": 1.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 24099.67, "maximum": 24099.67, "setting": "inpatient", "gross_charge": 40937.5, "discounted_cash": 28656.25, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 40937.5, "10th_percentile": 40937.5, "90th_percentile": 40937.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 40937.5, "10th_percentile": 40937.5, "90th_percentile": 40937.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; All IP Services - OON; 100% Billed", "median_amount": 40937.5, "10th_percentile": 40937.5, "90th_percentile": 40937.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; All Inpatient Services; 37% Billed", "median_amount": 15146.88, "10th_percentile": 15146.88, "90th_percentile": 15146.88, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_percentage": 25.4, "standard_charge_algorithm": "Additional drugs, labs, supplies, and therapy services can be included in reimbursement.", "median_amount": 10398.14, "10th_percentile": 10398.14, "90th_percentile": 10398.14, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 86.7, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; IP Services. ADP RATE (for patient estimates only); 86.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35492.81, "10th_percentile": 35492.81, "90th_percentile": 35492.81, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 76.7, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; IP Services. ADP RATE (for patient estimates only); 76.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31399.06, "10th_percentile": 31399.06, "90th_percentile": 31399.06, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 81.5, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; IP Services. ADP RATE (for patient estimates only); 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33364.06, "10th_percentile": 33364.06, "90th_percentile": 33364.06, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 76.7, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; IP Services. ADP RATE (for patient estimates only); 76.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31399.06, "10th_percentile": 31399.06, "90th_percentile": 31399.06, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 49.0, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; 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": 20059.38, "10th_percentile": 20059.38, "90th_percentile": 20059.38, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 86.7, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; IP Services. ADP RATE (for patient estimates only); 86.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35492.81, "10th_percentile": 35492.81, "90th_percentile": 35492.81, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; Inpatient; 69% Billed", "median_amount": 28246.88, "10th_percentile": 28246.88, "90th_percentile": 28246.88, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs, labs, supplies, and therapy services can be included in reimbursement.", "median_amount": 34796.88, "10th_percentile": 34796.88, "90th_percentile": 34796.88, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_percentage": 45.0, "standard_charge_algorithm": "Additional drugs, labs, supplies, and therapy services can be included in reimbursement.", "median_amount": 18421.88, "10th_percentile": 18421.88, "90th_percentile": 18421.88, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; Inpatient Services; 75% Billed", "median_amount": 30703.13, "10th_percentile": 30703.13, "90th_percentile": 30703.13, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_percentage": 87.5, "standard_charge_algorithm": "Additional drugs, labs, supplies, and therapy services can be included in reimbursement.", "median_amount": 35820.33, "10th_percentile": 35820.33, "90th_percentile": 35820.33, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; Inpatient Services; 54.35% Billed", "median_amount": 22249.53, "10th_percentile": 22249.53, "90th_percentile": 22249.53, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 24099.67, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 21,401.00, and; Pricing Extension - NM HB XR PRC - VWH 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": 24099.67, "10th_percentile": 24099.67, "90th_percentile": 24099.67, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 24099.67, "standard_charge_algorithm": "Re-evaluated: HLB.870424752; Using new claim; Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 21,401.00, and; Pricing Extension - NM HB XR PRC - VWH 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": 24099.67, "10th_percentile": 24099.67, "90th_percentile": 24099.67, "count": "11", "methodology": "case rate" } ] } ] }, { "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": 91.84, "maximum": 1331.0, "setting": "outpatient", "gross_charge": 1331.0, "discounted_cash": 931.7, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 252.89, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 252.89, "10th_percentile": 252.89, "90th_percentile": 252.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 252.89, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 252.89, "10th_percentile": 252.89, "90th_percentile": 252.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 252.89, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 252.89, "10th_percentile": 252.89, "90th_percentile": 252.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 838.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 838.53, "10th_percentile": 838.53, "90th_percentile": 838.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1087.43, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1087.43, "10th_percentile": 1087.43, "90th_percentile": 1087.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 744.03, "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": 744.03, "10th_percentile": 744.03, "90th_percentile": 744.03, "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": "VWH BCBS HMO", "standard_charge_dollar": 867.15, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 867.15, "10th_percentile": 867.15, "90th_percentile": 867.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 803.92, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 803.92, "10th_percentile": 803.92, "90th_percentile": 803.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 803.92, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 803.92, "10th_percentile": 803.92, "90th_percentile": 803.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1331.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1331.0, "10th_percentile": 1331.0, "90th_percentile": 1331.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1331.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1331.0, "10th_percentile": 1331.0, "90th_percentile": 1331.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1131.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1131.35, "10th_percentile": 1131.35, "90th_percentile": 1131.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1164.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1164.63, "10th_percentile": 1164.63, "90th_percentile": 1164.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 338.07, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 338.07, "10th_percentile": 338.07, "90th_percentile": 338.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1331.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1331.0, "10th_percentile": 1331.0, "90th_percentile": 1331.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 598.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 598.95, "10th_percentile": 598.95, "90th_percentile": 598.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1064.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1064.8, "10th_percentile": 1064.8, "90th_percentile": 1064.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 867.15, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 867.15, "10th_percentile": 867.15, "90th_percentile": 867.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 723.4, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 723.4, "10th_percentile": 723.4, "90th_percentile": 723.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 897.09, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 897.09, "10th_percentile": 897.09, "90th_percentile": 897.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 998.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 998.25, "10th_percentile": 998.25, "90th_percentile": 998.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1087.43, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1087.43, "10th_percentile": 1087.43, "90th_percentile": 1087.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 463.19, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 463.19, "10th_percentile": 463.19, "90th_percentile": 463.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 91.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 91.84, "10th_percentile": 91.84, "90th_percentile": 91.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 91.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 91.84, "10th_percentile": 91.84, "90th_percentile": 91.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 91.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 91.84, "10th_percentile": 91.84, "90th_percentile": 91.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 91.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 91.84, "10th_percentile": 91.84, "90th_percentile": 91.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 91.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 91.84, "10th_percentile": 91.84, "90th_percentile": 91.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 91.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 91.84, "10th_percentile": 91.84, "90th_percentile": 91.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "ALBUMIN, HUMAN-KJDA 25 % 25 % IV SOLN", "drug_information": { "unit": 50.0, "type": "ML" }, "code_information": [ { "code": "RX-217245", "type": "CDM" }, { "code": "P9047", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "64208-2512-03", "type": "NDC" } ], "standard_charges": [ { "minimum": 37.85, "maximum": 548.5, "setting": "outpatient", "gross_charge": 548.5, "discounted_cash": 383.95, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 104.22, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 104.22, "10th_percentile": 104.22, "90th_percentile": 104.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 104.22, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 104.22, "10th_percentile": 104.22, "90th_percentile": 104.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 104.22, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 104.22, "10th_percentile": 104.22, "90th_percentile": 104.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 345.56, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 345.56, "10th_percentile": 345.56, "90th_percentile": 345.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 448.12, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.12, "10th_percentile": 448.12, "90th_percentile": 448.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 306.61, "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": 306.61, "10th_percentile": 306.61, "90th_percentile": 306.61, "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": "VWH BCBS HMO", "standard_charge_dollar": 357.35, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 357.35, "10th_percentile": 357.35, "90th_percentile": 357.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 331.29, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.29, "10th_percentile": 331.29, "90th_percentile": 331.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 331.29, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.29, "10th_percentile": 331.29, "90th_percentile": 331.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.5, "10th_percentile": 548.5, "90th_percentile": 548.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.5, "10th_percentile": 548.5, "90th_percentile": 548.5, "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": "VWH HFN", "standard_charge_dollar": 466.23, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 466.23, "10th_percentile": 466.23, "90th_percentile": 466.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 479.94, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 479.94, "10th_percentile": 479.94, "90th_percentile": 479.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 139.32, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 139.32, "10th_percentile": 139.32, "90th_percentile": 139.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 548.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 548.5, "10th_percentile": 548.5, "90th_percentile": 548.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 246.83, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 246.83, "10th_percentile": 246.83, "90th_percentile": 246.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 438.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 438.8, "10th_percentile": 438.8, "90th_percentile": 438.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 357.35, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 357.35, "10th_percentile": 357.35, "90th_percentile": 357.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 298.11, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 298.11, "10th_percentile": 298.11, "90th_percentile": 298.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 369.69, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 369.69, "10th_percentile": 369.69, "90th_percentile": 369.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 411.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 411.38, "10th_percentile": 411.38, "90th_percentile": 411.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 448.12, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.12, "10th_percentile": 448.12, "90th_percentile": 448.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 190.88, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 190.88, "10th_percentile": 190.88, "90th_percentile": 190.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 37.85, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 37.85, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 37.85, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 37.85, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 37.85, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 37.85, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "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": 5.8, "maximum": 30.5, "setting": "outpatient", "gross_charge": 30.5, "discounted_cash": 21.35, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 19.95, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.95, "10th_percentile": 19.95, "90th_percentile": 19.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 21.14, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.14, "10th_percentile": 21.14, "90th_percentile": 21.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 10.61, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 10.61, "10th_percentile": 10.61, "90th_percentile": 10.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 7.75, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 7.75, "10th_percentile": 7.75, "90th_percentile": 7.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 5.8, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 5.8, "10th_percentile": 5.8, "90th_percentile": 5.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 19.87, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 19.87, "10th_percentile": 19.87, "90th_percentile": 19.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 24.86, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.86, "10th_percentile": 24.86, "90th_percentile": 24.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 5.8, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 5.8, "10th_percentile": 5.8, "90th_percentile": 5.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 20.45, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.45, "10th_percentile": 20.45, "90th_percentile": 20.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 19.25, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.25, "10th_percentile": 19.25, "90th_percentile": 19.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 17.19, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.19, "10th_percentile": 17.19, "90th_percentile": 17.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 19.87, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 19.87, "10th_percentile": 19.87, "90th_percentile": 19.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 17.05, "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": 17.05, "10th_percentile": 17.05, "90th_percentile": 17.05, "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": "VWH BCBS PPO", "standard_charge_dollar": 24.86, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.86, "10th_percentile": 24.86, "90th_percentile": 24.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 20.56, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 20.56, "10th_percentile": 20.56, "90th_percentile": 20.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 13.82, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.82, "10th_percentile": 13.82, "90th_percentile": 13.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 14.73, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.73, "10th_percentile": 14.73, "90th_percentile": 14.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 5.8, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 5.8, "10th_percentile": 5.8, "90th_percentile": 5.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 25.93, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 25.93, "10th_percentile": 25.93, "90th_percentile": 25.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 13.73, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 13.73, "10th_percentile": 13.73, "90th_percentile": 13.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 22.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 22.88, "10th_percentile": 22.88, "90th_percentile": 22.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 26.69, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 26.69, "10th_percentile": 26.69, "90th_percentile": 26.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 24.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 24.4, "10th_percentile": 24.4, "90th_percentile": 24.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 16.58, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 16.58, "10th_percentile": 16.58, "90th_percentile": 16.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 15.31, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.31, "10th_percentile": 15.31, "90th_percentile": 15.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 20.4, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.4, "10th_percentile": 20.4, "90th_percentile": 20.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 30.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "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": "76204-0027-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.7, "maximum": 30.0, "setting": "outpatient", "gross_charge": 30.0, "discounted_cash": 21.0, "payers_information": [ { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 14.49, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.49, "10th_percentile": 14.49, "90th_percentile": 14.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 5.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 5.7, "10th_percentile": 5.7, "90th_percentile": 5.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 25.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 25.5, "10th_percentile": 25.5, "90th_percentile": 25.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 13.5, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 22.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 26.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 26.25, "10th_percentile": 26.25, "90th_percentile": 26.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 24.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 16.31, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 16.31, "10th_percentile": 16.31, "90th_percentile": 16.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 15.06, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.06, "10th_percentile": 15.06, "90th_percentile": 15.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 20.07, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.07, "10th_percentile": 20.07, "90th_percentile": 20.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 30.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 19.62, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.62, "10th_percentile": 19.62, "90th_percentile": 19.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 20.79, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.79, "10th_percentile": 20.79, "90th_percentile": 20.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 10.44, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% 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 Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 7.62, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 7.62, "10th_percentile": 7.62, "90th_percentile": 7.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 5.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 5.7, "10th_percentile": 5.7, "90th_percentile": 5.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 19.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 19.55, "10th_percentile": 19.55, "90th_percentile": 19.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 24.45, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.45, "10th_percentile": 24.45, "90th_percentile": 24.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 5.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 5.7, "10th_percentile": 5.7, "90th_percentile": 5.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 20.12, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.12, "10th_percentile": 20.12, "90th_percentile": 20.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 18.93, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.93, "10th_percentile": 18.93, "90th_percentile": 18.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 16.91, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.91, "10th_percentile": 16.91, "90th_percentile": 16.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 19.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 19.55, "10th_percentile": 19.55, "90th_percentile": 19.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 16.77, "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": 16.77, "10th_percentile": 16.77, "90th_percentile": 16.77, "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": "VWH BCBS PPO", "standard_charge_dollar": 24.45, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.45, "10th_percentile": 24.45, "90th_percentile": 24.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 20.22, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 20.22, "10th_percentile": 20.22, "90th_percentile": 20.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 13.59, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.59, "10th_percentile": 13.59, "90th_percentile": 13.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": 196.18, "maximum": 1032.5, "setting": "outpatient", "gross_charge": 1032.5, "discounted_cash": 722.75, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1032.5, "10th_percentile": 1032.5, "90th_percentile": 1032.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1032.5, "10th_percentile": 1032.5, "90th_percentile": 1032.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1032.5, "10th_percentile": 1032.5, "90th_percentile": 1032.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1032.5, "10th_percentile": 1032.5, "90th_percentile": 1032.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1032.5, "10th_percentile": 1032.5, "90th_percentile": 1032.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1032.5, "10th_percentile": 1032.5, "90th_percentile": 1032.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 561.16, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 561.16, "10th_percentile": 561.16, "90th_percentile": 561.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 826.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 826.0, "10th_percentile": 826.0, "90th_percentile": 826.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 774.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 774.38, "10th_percentile": 774.38, "90th_percentile": 774.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 695.91, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 695.91, "10th_percentile": 695.91, "90th_percentile": 695.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 467.72, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.72, "10th_percentile": 467.72, "90th_percentile": 467.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 672.67, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 672.67, "10th_percentile": 672.67, "90th_percentile": 672.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 498.7, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 498.7, "10th_percentile": 498.7, "90th_percentile": 498.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 903.44, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 903.44, "10th_percentile": 903.44, "90th_percentile": 903.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 464.63, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 877.63, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 877.63, "10th_percentile": 877.63, "90th_percentile": 877.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 841.49, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 841.49, "10th_percentile": 841.49, "90th_percentile": 841.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 196.18, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 196.18, "10th_percentile": 196.18, "90th_percentile": 196.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1032.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1032.5, "10th_percentile": 1032.5, "90th_percentile": 1032.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 690.74, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 690.74, "10th_percentile": 690.74, "90th_percentile": 690.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 518.32, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 518.32, "10th_percentile": 518.32, "90th_percentile": 518.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 675.26, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 675.26, "10th_percentile": 675.26, "90th_percentile": 675.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 715.52, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 715.52, "10th_percentile": 715.52, "90th_percentile": 715.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 359.31, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 359.31, "10th_percentile": 359.31, "90th_percentile": 359.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 262.26, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 262.26, "10th_percentile": 262.26, "90th_percentile": 262.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 196.18, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 196.18, "10th_percentile": 196.18, "90th_percentile": 196.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 196.18, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 196.18, "10th_percentile": 196.18, "90th_percentile": 196.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1032.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1032.5, "10th_percentile": 1032.5, "90th_percentile": 1032.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1032.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1032.5, "10th_percentile": 1032.5, "90th_percentile": 1032.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 651.61, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 651.61, "10th_percentile": 651.61, "90th_percentile": 651.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 841.49, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 841.49, "10th_percentile": 841.49, "90th_percentile": 841.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 672.67, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 672.67, "10th_percentile": 672.67, "90th_percentile": 672.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 581.81, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.81, "10th_percentile": 581.81, "90th_percentile": 581.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 577.17, "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": 577.17, "10th_percentile": 577.17, "90th_percentile": 577.17, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 692.39, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 692.39, "10th_percentile": 692.39, "90th_percentile": 692.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AMINO ACID 8 % IN D14W 8-14 % IV SOLP", "drug_information": { "unit": 2000.0, "type": "ML" }, "code_information": [ { "code": "RX-227245", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00338-0184-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 158.75, "maximum": 835.5, "setting": "outpatient", "gross_charge": 835.5, "discounted_cash": 584.85, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 835.5, "10th_percentile": 835.5, "90th_percentile": 835.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 835.5, "10th_percentile": 835.5, "90th_percentile": 835.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 835.5, "10th_percentile": 835.5, "90th_percentile": 835.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 835.5, "10th_percentile": 835.5, "90th_percentile": 835.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 835.5, "10th_percentile": 835.5, "90th_percentile": 835.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 835.5, "10th_percentile": 835.5, "90th_percentile": 835.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 680.93, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 680.93, "10th_percentile": 680.93, "90th_percentile": 680.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 467.04, "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": 467.04, "10th_percentile": 467.04, "90th_percentile": 467.04, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 560.29, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 560.29, "10th_percentile": 560.29, "90th_percentile": 560.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 527.28, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 527.28, "10th_percentile": 527.28, "90th_percentile": 527.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 470.8, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 470.8, "10th_percentile": 470.8, "90th_percentile": 470.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 544.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 544.33, "10th_percentile": 544.33, "90th_percentile": 544.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 835.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 835.5, "10th_percentile": 835.5, "90th_percentile": 835.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 835.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 835.5, "10th_percentile": 835.5, "90th_percentile": 835.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 158.75, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 158.75, "10th_percentile": 158.75, "90th_percentile": 158.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 158.75, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 158.75, "10th_percentile": 158.75, "90th_percentile": 158.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 212.22, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 212.22, "10th_percentile": 212.22, "90th_percentile": 212.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 290.75, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 290.75, "10th_percentile": 290.75, "90th_percentile": 290.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 579.0, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 579.0, "10th_percentile": 579.0, "90th_percentile": 579.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 546.42, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 546.42, "10th_percentile": 546.42, "90th_percentile": 546.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 835.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 835.5, "10th_percentile": 835.5, "90th_percentile": 835.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 419.42, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 419.42, "10th_percentile": 419.42, "90th_percentile": 419.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 558.95, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 558.95, "10th_percentile": 558.95, "90th_percentile": 558.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 563.13, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 563.13, "10th_percentile": 563.13, "90th_percentile": 563.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 710.18, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 710.18, "10th_percentile": 710.18, "90th_percentile": 710.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 668.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 668.4, "10th_percentile": 668.4, "90th_percentile": 668.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 544.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 544.33, "10th_percentile": 544.33, "90th_percentile": 544.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 375.98, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 375.98, "10th_percentile": 375.98, "90th_percentile": 375.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 403.55, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 403.55, "10th_percentile": 403.55, "90th_percentile": 403.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 680.93, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 680.93, "10th_percentile": 680.93, "90th_percentile": 680.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 626.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 626.63, "10th_percentile": 626.63, "90th_percentile": 626.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 378.48, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 378.48, "10th_percentile": 378.48, "90th_percentile": 378.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 731.06, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 731.06, "10th_percentile": 731.06, "90th_percentile": 731.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 454.09, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 454.09, "10th_percentile": 454.09, "90th_percentile": 454.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 158.75, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 158.75, "10th_percentile": 158.75, "90th_percentile": 158.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% 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": 6.74, "maximum": 97.75, "setting": "outpatient", "gross_charge": 97.75, "discounted_cash": 68.42, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 18.57, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 18.57, "10th_percentile": 18.57, "90th_percentile": 18.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 18.57, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 18.57, "10th_percentile": 18.57, "90th_percentile": 18.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 18.57, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 18.57, "10th_percentile": 18.57, "90th_percentile": 18.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 61.58, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.58, "10th_percentile": 61.58, "90th_percentile": 61.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 79.86, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.86, "10th_percentile": 79.86, "90th_percentile": 79.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 54.64, "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": 54.64, "10th_percentile": 54.64, "90th_percentile": 54.64, "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": "VWH BCBS HMO", "standard_charge_dollar": 63.68, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 63.68, "10th_percentile": 63.68, "90th_percentile": 63.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 59.04, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.04, "10th_percentile": 59.04, "90th_percentile": 59.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 59.04, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.04, "10th_percentile": 59.04, "90th_percentile": 59.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 97.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 97.75, "10th_percentile": 97.75, "90th_percentile": 97.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 97.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 97.75, "10th_percentile": 97.75, "90th_percentile": 97.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 83.09, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 83.09, "10th_percentile": 83.09, "90th_percentile": 83.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 85.53, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 85.53, "10th_percentile": 85.53, "90th_percentile": 85.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 24.83, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 24.83, "10th_percentile": 24.83, "90th_percentile": 24.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 97.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 97.75, "10th_percentile": 97.75, "90th_percentile": 97.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 43.99, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 43.99, "10th_percentile": 43.99, "90th_percentile": 43.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 78.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 78.2, "10th_percentile": 78.2, "90th_percentile": 78.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 63.68, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 63.68, "10th_percentile": 63.68, "90th_percentile": 63.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 53.13, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 53.13, "10th_percentile": 53.13, "90th_percentile": 53.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 65.88, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 65.88, "10th_percentile": 65.88, "90th_percentile": 65.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 73.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 73.31, "10th_percentile": 73.31, "90th_percentile": 73.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 79.86, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.86, "10th_percentile": 79.86, "90th_percentile": 79.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 34.02, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 34.02, "10th_percentile": 34.02, "90th_percentile": 34.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.74, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.74, "10th_percentile": 6.74, "90th_percentile": 6.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.74, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.74, "10th_percentile": 6.74, "90th_percentile": 6.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.74, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.74, "10th_percentile": 6.74, "90th_percentile": 6.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.74, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.74, "10th_percentile": 6.74, "90th_percentile": 6.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.74, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.74, "10th_percentile": 6.74, "90th_percentile": 6.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.74, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.74, "10th_percentile": 6.74, "90th_percentile": 6.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "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": 28.93, "maximum": 419.25, "setting": "outpatient", "gross_charge": 419.25, "discounted_cash": 293.47, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 79.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 79.66, "10th_percentile": 79.66, "90th_percentile": 79.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 79.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 79.66, "10th_percentile": 79.66, "90th_percentile": 79.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 79.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 79.66, "10th_percentile": 79.66, "90th_percentile": 79.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 264.13, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 264.13, "10th_percentile": 264.13, "90th_percentile": 264.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 342.53, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 234.36, "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": 234.36, "10th_percentile": 234.36, "90th_percentile": 234.36, "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": "VWH BCBS HMO", "standard_charge_dollar": 273.14, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 273.14, "10th_percentile": 273.14, "90th_percentile": 273.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 253.23, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 253.23, "10th_percentile": 253.23, "90th_percentile": 253.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 253.23, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 253.23, "10th_percentile": 253.23, "90th_percentile": 253.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 419.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 419.25, "10th_percentile": 419.25, "90th_percentile": 419.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 419.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 419.25, "10th_percentile": 419.25, "90th_percentile": 419.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 356.36, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 356.36, "10th_percentile": 356.36, "90th_percentile": 356.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 366.84, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 366.84, "10th_percentile": 366.84, "90th_percentile": 366.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 106.49, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 106.49, "10th_percentile": 106.49, "90th_percentile": 106.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 419.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 419.25, "10th_percentile": 419.25, "90th_percentile": 419.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 188.66, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 188.66, "10th_percentile": 188.66, "90th_percentile": 188.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 335.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 335.4, "10th_percentile": 335.4, "90th_percentile": 335.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 273.14, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 273.14, "10th_percentile": 273.14, "90th_percentile": 273.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 227.86, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 227.86, "10th_percentile": 227.86, "90th_percentile": 227.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 282.57, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 282.57, "10th_percentile": 282.57, "90th_percentile": 282.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 314.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 314.44, "10th_percentile": 314.44, "90th_percentile": 314.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 342.53, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 145.9, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 145.9, "10th_percentile": 145.9, "90th_percentile": 145.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 28.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 28.93, "10th_percentile": 28.93, "90th_percentile": 28.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 28.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 28.93, "10th_percentile": 28.93, "90th_percentile": 28.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 28.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 28.93, "10th_percentile": 28.93, "90th_percentile": 28.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 28.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 28.93, "10th_percentile": 28.93, "90th_percentile": 28.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 28.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 28.93, "10th_percentile": 28.93, "90th_percentile": 28.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 28.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 28.93, "10th_percentile": 28.93, "90th_percentile": 28.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "AMMONIUM LACTATE 12 % TOP LOTN", "drug_information": { "unit": 225.0, "type": "GR" }, "code_information": [ { "code": "RX-10380", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "45802-0525-55", "type": "NDC" } ], "standard_charges": [ { "minimum": 115.95, "maximum": 610.25, "setting": "outpatient", "gross_charge": 610.25, "discounted_cash": 427.17, "payers_information": [ { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 497.35, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 497.35, "10th_percentile": 497.35, "90th_percentile": 497.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 341.13, "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": 341.13, "10th_percentile": 341.13, "90th_percentile": 341.13, "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 397.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 397.58, "10th_percentile": 397.58, "90th_percentile": 397.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 343.88, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 343.88, "10th_percentile": 343.88, "90th_percentile": 343.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 385.13, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 385.13, "10th_percentile": 385.13, "90th_percentile": 385.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 409.23, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 409.23, "10th_percentile": 409.23, "90th_percentile": 409.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 115.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 115.95, "10th_percentile": 115.95, "90th_percentile": 115.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 115.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 115.95, "10th_percentile": 115.95, "90th_percentile": 115.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 610.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 610.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 155.0, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 155.0, "10th_percentile": 155.0, "90th_percentile": 155.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 212.37, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% 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 Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 422.9, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 422.9, "10th_percentile": 422.9, "90th_percentile": 422.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 399.1, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 399.1, "10th_percentile": 399.1, "90th_percentile": 399.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 306.35, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 306.35, "10th_percentile": 306.35, "90th_percentile": 306.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 408.26, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 408.26, "10th_percentile": 408.26, "90th_percentile": 408.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 610.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 115.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 115.95, "10th_percentile": 115.95, "90th_percentile": 115.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 397.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 397.58, "10th_percentile": 397.58, "90th_percentile": 397.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 497.35, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 497.35, "10th_percentile": 497.35, "90th_percentile": 497.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 411.31, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 411.31, "10th_percentile": 411.31, "90th_percentile": 411.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 276.44, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 276.44, "10th_percentile": 276.44, "90th_percentile": 276.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 294.75, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 294.75, "10th_percentile": 294.75, "90th_percentile": 294.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 518.71, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 518.71, "10th_percentile": 518.71, "90th_percentile": 518.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 274.61, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 274.61, "10th_percentile": 274.61, "90th_percentile": 274.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 457.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 457.69, "10th_percentile": 457.69, "90th_percentile": 457.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 533.97, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 533.97, "10th_percentile": 533.97, "90th_percentile": 533.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 488.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 488.2, "10th_percentile": 488.2, "90th_percentile": 488.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 331.67, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 331.67, "10th_percentile": 331.67, "90th_percentile": 331.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% 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": 3.28, "maximum": 17.25, "setting": "outpatient", "gross_charge": 17.25, "discounted_cash": 12.07, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 3.28, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3.28, "10th_percentile": 3.28, "90th_percentile": 3.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 13.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 13.8, "10th_percentile": 13.8, "90th_percentile": 13.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 8.33, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.33, "10th_percentile": 8.33, "90th_percentile": 8.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 7.81, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 12.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 12.94, "10th_percentile": 12.94, "90th_percentile": 12.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 7.76, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 7.76, "10th_percentile": 7.76, "90th_percentile": 7.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 11.24, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 11.24, "10th_percentile": 11.24, "90th_percentile": 11.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 15.09, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 15.09, "10th_percentile": 15.09, "90th_percentile": 15.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 11.63, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 11.63, "10th_percentile": 11.63, "90th_percentile": 11.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 14.06, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 14.66, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 14.66, "10th_percentile": 14.66, "90th_percentile": 14.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 9.38, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 9.38, "10th_percentile": 9.38, "90th_percentile": 9.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 8.66, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.66, "10th_percentile": 8.66, "90th_percentile": 8.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 11.54, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.54, "10th_percentile": 11.54, "90th_percentile": 11.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 11.95, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.95, "10th_percentile": 11.95, "90th_percentile": 11.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.38, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 4.38, "10th_percentile": 4.38, "90th_percentile": 4.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 6.0, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% 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 Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 11.28, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.28, "10th_percentile": 11.28, "90th_percentile": 11.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 3.28, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "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; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3.28, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "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; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9.72, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.72, "10th_percentile": 9.72, "90th_percentile": 9.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10.89, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.89, "10th_percentile": 10.89, "90th_percentile": 10.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 11.24, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 11.24, "10th_percentile": 11.24, "90th_percentile": 11.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 14.06, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11.57, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.57, "10th_percentile": 11.57, "90th_percentile": 11.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9.64, "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": 9.64, "10th_percentile": 9.64, "90th_percentile": 9.64, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "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": 2.83, "maximum": 41.0, "setting": "outpatient", "gross_charge": 41.0, "discounted_cash": 28.7, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 41.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 41.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 33.5, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.5, "10th_percentile": 33.5, "90th_percentile": 33.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH THE ALLIANCE", "standard_charge_dollar": 22.28, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 22.28, "10th_percentile": 22.28, "90th_percentile": 22.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 26.71, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 26.71, "10th_percentile": 26.71, "90th_percentile": 26.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 10.41, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 10.41, "10th_percentile": 10.41, "90th_percentile": 10.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 35.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 35.88, "10th_percentile": 35.88, "90th_percentile": 35.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 18.45, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 18.45, "10th_percentile": 18.45, "90th_percentile": 18.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 34.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 34.85, "10th_percentile": 34.85, "90th_percentile": 34.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 32.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 32.8, "10th_percentile": 32.8, "90th_percentile": 32.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 41.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 30.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 30.75, "10th_percentile": 30.75, "90th_percentile": 30.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 14.27, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 14.27, "10th_percentile": 14.27, "90th_percentile": 14.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 27.63, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 27.63, "10th_percentile": 27.63, "90th_percentile": 27.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 33.5, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.5, "10th_percentile": 33.5, "90th_percentile": 33.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 25.83, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.83, "10th_percentile": 25.83, "90th_percentile": 25.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 26.71, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 26.71, "10th_percentile": 26.71, "90th_percentile": 26.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 22.92, "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": 22.92, "10th_percentile": 22.92, "90th_percentile": 22.92, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 24.76, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.76, "10th_percentile": 24.76, "90th_percentile": 24.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 24.76, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.76, "10th_percentile": 24.76, "90th_percentile": 24.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 7.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 7.79, "10th_percentile": 7.79, "90th_percentile": 7.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 7.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 7.79, "10th_percentile": 7.79, "90th_percentile": 7.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 7.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 7.79, "10th_percentile": 7.79, "90th_percentile": 7.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.83, "10th_percentile": 2.83, "90th_percentile": 2.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.83, "10th_percentile": 2.83, "90th_percentile": 2.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.83, "10th_percentile": 2.83, "90th_percentile": 2.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.83, "10th_percentile": 2.83, "90th_percentile": 2.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.83, "10th_percentile": 2.83, "90th_percentile": 2.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.83, "10th_percentile": 2.83, "90th_percentile": 2.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "ARGATROBAN 100 MG/ML IV SOLN", "drug_information": { "unit": 2.5, "type": "ML" }, "code_information": [ { "code": "RX-28947", "type": "CDM" }, { "code": "J0883", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00143-9674-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 79.45, "maximum": 1151.5, "setting": "outpatient", "gross_charge": 1151.5, "discounted_cash": 806.05, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 218.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 218.79, "10th_percentile": 218.79, "90th_percentile": 218.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 218.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 218.79, "10th_percentile": 218.79, "90th_percentile": 218.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 218.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 218.79, "10th_percentile": 218.79, "90th_percentile": 218.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 725.45, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 725.45, "10th_percentile": 725.45, "90th_percentile": 725.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 940.78, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 940.78, "10th_percentile": 940.78, "90th_percentile": 940.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 643.69, "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": 643.69, "10th_percentile": 643.69, "90th_percentile": 643.69, "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": "VWH BCBS HMO", "standard_charge_dollar": 750.2, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 750.2, "10th_percentile": 750.2, "90th_percentile": 750.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 695.51, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 695.51, "10th_percentile": 695.51, "90th_percentile": 695.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 695.51, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 695.51, "10th_percentile": 695.51, "90th_percentile": 695.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1151.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1151.5, "10th_percentile": 1151.5, "90th_percentile": 1151.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1151.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1151.5, "10th_percentile": 1151.5, "90th_percentile": 1151.5, "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": "VWH HFN", "standard_charge_dollar": 978.78, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 978.78, "10th_percentile": 978.78, "90th_percentile": 978.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1007.56, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1007.56, "10th_percentile": 1007.56, "90th_percentile": 1007.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 292.48, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 292.48, "10th_percentile": 292.48, "90th_percentile": 292.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1151.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1151.5, "10th_percentile": 1151.5, "90th_percentile": 1151.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 518.18, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 518.18, "10th_percentile": 518.18, "90th_percentile": 518.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 921.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 921.2, "10th_percentile": 921.2, "90th_percentile": 921.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 750.2, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 750.2, "10th_percentile": 750.2, "90th_percentile": 750.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 625.84, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 625.84, "10th_percentile": 625.84, "90th_percentile": 625.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 776.11, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 776.11, "10th_percentile": 776.11, "90th_percentile": 776.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 863.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 863.63, "10th_percentile": 863.63, "90th_percentile": 863.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 940.78, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 940.78, "10th_percentile": 940.78, "90th_percentile": 940.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 400.72, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 400.72, "10th_percentile": 400.72, "90th_percentile": 400.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 79.45, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 79.45, "10th_percentile": 79.45, "90th_percentile": 79.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 79.45, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 79.45, "10th_percentile": 79.45, "90th_percentile": 79.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 79.45, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 79.45, "10th_percentile": 79.45, "90th_percentile": 79.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 79.45, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 79.45, "10th_percentile": 79.45, "90th_percentile": 79.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 79.45, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 79.45, "10th_percentile": 79.45, "90th_percentile": 79.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 79.45, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 79.45, "10th_percentile": 79.45, "90th_percentile": 79.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "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": 38.57, "maximum": 559.0, "setting": "outpatient", "gross_charge": 559.0, "discounted_cash": 391.3, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 106.21, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 106.21, "10th_percentile": 106.21, "90th_percentile": 106.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 106.21, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 106.21, "10th_percentile": 106.21, "90th_percentile": 106.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 106.21, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 106.21, "10th_percentile": 106.21, "90th_percentile": 106.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 352.17, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 352.17, "10th_percentile": 352.17, "90th_percentile": 352.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 456.7, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 456.7, "10th_percentile": 456.7, "90th_percentile": 456.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 312.48, "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": 312.48, "10th_percentile": 312.48, "90th_percentile": 312.48, "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": "VWH BCBS HMO", "standard_charge_dollar": 364.19, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 364.19, "10th_percentile": 364.19, "90th_percentile": 364.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 337.64, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 337.64, "10th_percentile": 337.64, "90th_percentile": 337.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 337.64, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 337.64, "10th_percentile": 337.64, "90th_percentile": 337.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 559.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 559.0, "10th_percentile": 559.0, "90th_percentile": 559.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 559.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 559.0, "10th_percentile": 559.0, "90th_percentile": 559.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 475.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 475.15, "10th_percentile": 475.15, "90th_percentile": 475.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 489.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 489.13, "10th_percentile": 489.13, "90th_percentile": 489.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 141.99, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 141.99, "10th_percentile": 141.99, "90th_percentile": 141.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 559.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 559.0, "10th_percentile": 559.0, "90th_percentile": 559.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 251.55, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 251.55, "10th_percentile": 251.55, "90th_percentile": 251.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 447.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 447.2, "10th_percentile": 447.2, "90th_percentile": 447.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 364.19, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 364.19, "10th_percentile": 364.19, "90th_percentile": 364.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 303.82, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 303.82, "10th_percentile": 303.82, "90th_percentile": 303.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 376.77, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 376.77, "10th_percentile": 376.77, "90th_percentile": 376.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 419.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 419.25, "10th_percentile": 419.25, "90th_percentile": 419.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 456.7, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 456.7, "10th_percentile": 456.7, "90th_percentile": 456.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 194.53, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 194.53, "10th_percentile": 194.53, "90th_percentile": 194.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.57, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.57, "10th_percentile": 38.57, "90th_percentile": 38.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.57, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.57, "10th_percentile": 38.57, "90th_percentile": 38.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.57, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.57, "10th_percentile": 38.57, "90th_percentile": 38.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.57, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.57, "10th_percentile": 38.57, "90th_percentile": 38.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.57, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.57, "10th_percentile": 38.57, "90th_percentile": 38.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.57, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.57, "10th_percentile": 38.57, "90th_percentile": 38.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_algorithm": "No contract line matched", "median_amount": 559.0, "10th_percentile": 559.0, "90th_percentile": 559.0, "count": "0", "methodology": "other", "additional_payer_notes": "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": 4.93, "maximum": 25.97, "setting": "outpatient", "gross_charge": 25.97, "discounted_cash": 18.18, "payers_information": [ { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.97, "10th_percentile": 25.97, "90th_percentile": 25.97, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.97, "10th_percentile": 25.97, "90th_percentile": 25.97, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.97, "10th_percentile": 25.97, "90th_percentile": 25.97, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.97, "10th_percentile": 25.97, "90th_percentile": 25.97, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.97, "10th_percentile": 25.97, "90th_percentile": 25.97, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.97, "10th_percentile": 25.97, "90th_percentile": 25.97, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 12.54, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.54, "10th_percentile": 12.54, "90th_percentile": 12.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 11.76, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.76, "10th_percentile": 11.76, "90th_percentile": 11.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 21.17, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.17, "10th_percentile": 21.17, "90th_percentile": 21.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 16.92, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 16.92, "10th_percentile": 16.92, "90th_percentile": 16.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 14.11, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 14.11, "10th_percentile": 14.11, "90th_percentile": 14.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 17.5, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 17.5, "10th_percentile": 17.5, "90th_percentile": 17.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 19.48, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 19.48, "10th_percentile": 19.48, "90th_percentile": 19.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 4.93, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 4.93, "10th_percentile": 4.93, "90th_percentile": 4.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 22.72, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 22.72, "10th_percentile": 22.72, "90th_percentile": 22.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 20.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 20.78, "10th_percentile": 20.78, "90th_percentile": 20.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 11.69, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 11.69, "10th_percentile": 11.69, "90th_percentile": 11.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 22.07, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 22.07, "10th_percentile": 22.07, "90th_percentile": 22.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 25.97, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 25.97, "10th_percentile": 25.97, "90th_percentile": 25.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 17.37, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.37, "10th_percentile": 17.37, "90th_percentile": 17.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 13.04, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.04, "10th_percentile": 13.04, "90th_percentile": 13.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 6.6, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 6.6, "10th_percentile": 6.6, "90th_percentile": 6.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 9.04, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 9.04, "10th_percentile": 9.04, "90th_percentile": 9.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 18.0, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.0, "10th_percentile": 18.0, "90th_percentile": 18.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 16.98, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.98, "10th_percentile": 16.98, "90th_percentile": 16.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 25.97, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 25.97, "10th_percentile": 25.97, "90th_percentile": 25.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 25.97, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 25.97, "10th_percentile": 25.97, "90th_percentile": 25.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 4.93, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 4.93, "10th_percentile": 4.93, "90th_percentile": 4.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 4.93, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 4.93, "10th_percentile": 4.93, "90th_percentile": 4.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 14.52, "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": 14.52, "10th_percentile": 14.52, "90th_percentile": 14.52, "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": "VWH BCBS HMO", "standard_charge_dollar": 16.92, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 16.92, "10th_percentile": 16.92, "90th_percentile": 16.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 16.39, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.39, "10th_percentile": 16.39, "90th_percentile": 16.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 17.42, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.42, "10th_percentile": 17.42, "90th_percentile": 17.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 21.17, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.17, "10th_percentile": 21.17, "90th_percentile": 21.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14.63, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.63, "10th_percentile": 14.63, "90th_percentile": 14.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "Arthroscopy Hip W/Femoroplasty", "code_information": [ { "code": "CASE-29914", "type": "LOCAL" }, { "code": "29914", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 95906.93, "discounted_cash": 67134.85, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH 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": 95906.93, "10th_percentile": 95906.93, "90th_percentile": 95906.93, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH 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": 95906.93, "10th_percentile": 95906.93, "90th_percentile": 95906.93, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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": 95906.93, "10th_percentile": 95906.93, "90th_percentile": 95906.93, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 62723.14, "10th_percentile": 62723.14, "90th_percentile": 62723.14, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 66463.5, "10th_percentile": 66463.5, "90th_percentile": 66463.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_percentage": 34.8, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 33375.62, "10th_percentile": 33375.62, "90th_percentile": 33375.62, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_percentage": 25.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 24360.37, "10th_percentile": 24360.37, "90th_percentile": 24360.37, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 18222.36, "10th_percentile": 18222.36, "90th_percentile": 18222.36, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 62483.37, "10th_percentile": 62483.37, "90th_percentile": 62483.37, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 76.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 73560.63, "10th_percentile": 73560.63, "90th_percentile": 73560.63, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 18222.36, "10th_percentile": 18222.36, "90th_percentile": 18222.36, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 57.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 55338.31, "10th_percentile": 55338.31, "90th_percentile": 55338.31, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 57.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 54858.75, "10th_percentile": 54858.75, "90th_percentile": 54858.75, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 57.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 55338.31, "10th_percentile": 55338.31, "90th_percentile": 55338.31, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 62483.37, "10th_percentile": 62483.37, "90th_percentile": 62483.37, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": 53611.99, "10th_percentile": 53611.99, "90th_percentile": 53611.99, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 76.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 73560.63, "10th_percentile": 73560.63, "90th_percentile": 73560.63, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6608.0, "10th_percentile": 6608.0, "90th_percentile": 6608.0, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 64641.27, "10th_percentile": 64641.27, "90th_percentile": 64641.27, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 41458.08, "10th_percentile": 41458.08, "90th_percentile": 41458.08, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 44101.16, "10th_percentile": 44101.16, "90th_percentile": 44101.16, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6608.0, "10th_percentile": 6608.0, "90th_percentile": 6608.0, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6608.0, "10th_percentile": 6608.0, "90th_percentile": 6608.0, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6608.0, "10th_percentile": 6608.0, "90th_percentile": 6608.0, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 18222.36, "10th_percentile": 18222.36, "90th_percentile": 18222.36, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6608.0, "10th_percentile": 6608.0, "90th_percentile": 6608.0, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 81520.93, "10th_percentile": 81520.93, "90th_percentile": 81520.93, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_percentage": 45.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 43158.15, "10th_percentile": 43158.15, "90th_percentile": 43158.15, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 71930.25, "10th_percentile": 71930.25, "90th_percentile": 71930.25, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6608.0, "10th_percentile": 6608.0, "90th_percentile": 6608.0, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_percentage": 87.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 83918.56, "10th_percentile": 83918.56, "90th_percentile": 83918.56, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 77739.15, "10th_percentile": 77739.15, "90th_percentile": 77739.15, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 52125.41, "10th_percentile": 52125.41, "90th_percentile": 52125.41, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 45997.07, "10th_percentile": 45997.07, "90th_percentile": 45997.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 60710.23, "10th_percentile": 60710.23, "90th_percentile": 60710.23, "count": "11", "methodology": "percent of total billed charges" } ] } ] }, { "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": 1.24, "maximum": 6.5, "setting": "outpatient", "gross_charge": 6.5, "discounted_cash": 4.55, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1.24, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1.24, "10th_percentile": 1.24, "90th_percentile": 1.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 5.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 5.2, "10th_percentile": 5.2, "90th_percentile": 5.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 3.14, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.94, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4.88, "10th_percentile": 4.88, "90th_percentile": 4.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2.93, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 4.23, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4.23, "10th_percentile": 4.23, "90th_percentile": 4.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 5.69, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 5.69, "10th_percentile": 5.69, "90th_percentile": 5.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 4.38, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 4.38, "10th_percentile": 4.38, "90th_percentile": 4.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 5.3, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 5.53, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% 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 Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3.53, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3.53, "10th_percentile": 3.53, "90th_percentile": 3.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 3.26, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.26, "10th_percentile": 3.26, "90th_percentile": 3.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 4.35, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 4.5, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.65, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1.65, "10th_percentile": 1.65, "90th_percentile": 1.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2.26, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2.26, "10th_percentile": 2.26, "90th_percentile": 2.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 4.25, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 1.24, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1.24, "10th_percentile": 1.24, "90th_percentile": 1.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1.24, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1.24, "10th_percentile": 1.24, "90th_percentile": 1.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.66, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.66, "10th_percentile": 3.66, "90th_percentile": 3.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.1, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.1, "10th_percentile": 4.1, "90th_percentile": 4.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 4.23, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4.23, "10th_percentile": 4.23, "90th_percentile": 4.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 5.3, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.36, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.36, "10th_percentile": 4.36, "90th_percentile": 4.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.63, "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": 3.63, "10th_percentile": 3.63, "90th_percentile": 3.63, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "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": 1.47, "maximum": 21.25, "setting": "outpatient", "gross_charge": 21.25, "discounted_cash": 14.87, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 4.04, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 4.04, "10th_percentile": 4.04, "90th_percentile": 4.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 4.04, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 4.04, "10th_percentile": 4.04, "90th_percentile": 4.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 4.04, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 4.04, "10th_percentile": 4.04, "90th_percentile": 4.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 13.39, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.39, "10th_percentile": 13.39, "90th_percentile": 13.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 17.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.36, "10th_percentile": 17.36, "90th_percentile": 17.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 11.88, "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": 11.88, "10th_percentile": 11.88, "90th_percentile": 11.88, "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": "VWH BCBS HMO", "standard_charge_dollar": 13.84, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 13.84, "10th_percentile": 13.84, "90th_percentile": 13.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 12.84, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.84, "10th_percentile": 12.84, "90th_percentile": 12.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 12.84, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.84, "10th_percentile": 12.84, "90th_percentile": 12.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 21.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 21.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 5.4, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% 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; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 7.4, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 7.4, "10th_percentile": 7.4, "90th_percentile": 7.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 14.73, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Drugs/Agents Default; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.73, "10th_percentile": 14.73, "90th_percentile": 14.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 13.9, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Drugs/Agents Default; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.9, "10th_percentile": 13.9, "90th_percentile": 13.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 21.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 14.22, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.22, "10th_percentile": 14.22, "90th_percentile": 14.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 10.67, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.67, "10th_percentile": 10.67, "90th_percentile": 10.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 14.32, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 14.32, "10th_percentile": 14.32, "90th_percentile": 14.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 18.06, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 18.06, "10th_percentile": 18.06, "90th_percentile": 18.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 9.56, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 9.56, "10th_percentile": 9.56, "90th_percentile": 9.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 15.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 15.94, "10th_percentile": 15.94, "90th_percentile": 15.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 18.59, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 18.59, "10th_percentile": 18.59, "90th_percentile": 18.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 17.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 17.0, "10th_percentile": 17.0, "90th_percentile": 17.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 11.55, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 11.55, "10th_percentile": 11.55, "90th_percentile": 11.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 13.84, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 13.84, "10th_percentile": 13.84, "90th_percentile": 13.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 17.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.36, "10th_percentile": 17.36, "90th_percentile": 17.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual 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": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1.47, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1.47, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1.47, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1.47, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1.47, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1.47, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "BASKET ZEROTIP 2.4FX120 RETRIV", "code_information": [ { "code": "SUP-317721", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 308.54, "maximum": 1623.89, "setting": "outpatient", "gross_charge": 1623.89, "discounted_cash": 1136.72, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1623.89, "10th_percentile": 1623.89, "90th_percentile": 1623.89, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1623.89, "10th_percentile": 1623.89, "90th_percentile": 1623.89, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1623.89, "10th_percentile": 1623.89, "90th_percentile": 1623.89, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1623.89, "10th_percentile": 1623.89, "90th_percentile": 1623.89, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1623.89, "10th_percentile": 1623.89, "90th_percentile": 1623.89, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1623.89, "10th_percentile": 1623.89, "90th_percentile": 1623.89, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 308.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 308.54, "10th_percentile": 308.54, "90th_percentile": 308.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1420.9, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1420.9, "10th_percentile": 1420.9, "90th_percentile": 1420.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1094.5, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1094.5, "10th_percentile": 1094.5, "90th_percentile": 1094.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1323.47, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1323.47, "10th_percentile": 1323.47, "90th_percentile": 1323.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 735.62, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 735.62, "10th_percentile": 735.62, "90th_percentile": 735.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 730.75, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 730.75, "10th_percentile": 730.75, "90th_percentile": 730.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1380.31, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1380.31, "10th_percentile": 1380.31, "90th_percentile": 1380.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 784.34, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 784.34, "10th_percentile": 784.34, "90th_percentile": 784.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1057.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1057.96, "10th_percentile": 1057.96, "90th_percentile": 1057.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1299.11, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1299.11, "10th_percentile": 1299.11, "90th_percentile": 1299.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 882.58, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 882.58, "10th_percentile": 882.58, "90th_percentile": 882.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1217.92, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1217.92, "10th_percentile": 1217.92, "90th_percentile": 1217.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1623.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1623.89, "10th_percentile": 1623.89, "90th_percentile": 1623.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1086.38, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1086.38, "10th_percentile": 1086.38, "90th_percentile": 1086.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 815.19, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 815.19, "10th_percentile": 815.19, "90th_percentile": 815.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 412.47, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 412.47, "10th_percentile": 412.47, "90th_percentile": 412.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1125.36, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1125.36, "10th_percentile": 1125.36, "90th_percentile": 1125.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 565.11, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 565.11, "10th_percentile": 565.11, "90th_percentile": 565.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1062.02, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1062.02, "10th_percentile": 1062.02, "90th_percentile": 1062.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1623.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1623.89, "10th_percentile": 1623.89, "90th_percentile": 1623.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1623.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1623.89, "10th_percentile": 1623.89, "90th_percentile": 1623.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 308.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 308.54, "10th_percentile": 308.54, "90th_percentile": 308.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 308.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 308.54, "10th_percentile": 308.54, "90th_percentile": 308.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 907.75, "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": 907.75, "10th_percentile": 907.75, "90th_percentile": 907.75, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 915.06, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 915.06, "10th_percentile": 915.06, "90th_percentile": 915.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1088.98, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1088.98, "10th_percentile": 1088.98, "90th_percentile": 1088.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1323.47, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1323.47, "10th_percentile": 1323.47, "90th_percentile": 1323.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1024.84, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1024.84, "10th_percentile": 1024.84, "90th_percentile": 1024.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1057.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1057.96, "10th_percentile": 1057.96, "90th_percentile": 1057.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 15388.71, "maximum": 19895.43, "setting": "inpatient", "gross_charge": 19513.74, "discounted_cash": 13659.62, "payers_information": [ { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 69% Billed", "median_amount": 13442.41, "10th_percentile": 13442.41, "90th_percentile": 13442.41, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient Services; 75% Billed", "median_amount": 14611.31, "10th_percentile": 14611.31, "90th_percentile": 14611.31, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient Services; 54.35% Billed", "median_amount": 10588.33, "10th_percentile": 10588.33, "90th_percentile": 10588.33, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_percentage": 87.5, "standard_charge_algorithm": "Additional drugs, imaging services, labs, and therapy services can be included in reimbursement.", "median_amount": 17046.56, "10th_percentile": 17046.56, "90th_percentile": 17046.56, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 49.0, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; 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": 9546.06, "10th_percentile": 9546.06, "90th_percentile": 9546.06, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All Inpatient Services; 37% Billed", "median_amount": 7208.25, "10th_percentile": 7208.25, "90th_percentile": 7208.25, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_percentage": 25.4, "standard_charge_algorithm": "Additional drugs, imaging services, labs, and therapy services can be included in reimbursement.", "median_amount": 4948.36, "10th_percentile": 4948.36, "90th_percentile": 4948.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_percentage": 45.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, and therapy services can be included in reimbursement.", "median_amount": 8766.79, "10th_percentile": 8766.79, "90th_percentile": 8766.79, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, and therapy services can be included in reimbursement.", "median_amount": 16559.49, "10th_percentile": 16559.49, "90th_percentile": 16559.49, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services - OON; 100% Billed", "median_amount": 19481.75, "10th_percentile": 19481.75, "90th_percentile": 19481.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 19481.75, "10th_percentile": 19481.75, "90th_percentile": 19481.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 19481.75, "10th_percentile": 19481.75, "90th_percentile": 19481.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15542.49, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 21,527.00, and; Pricing Extension - NM HB XR PRC - VWH 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": 15542.49, "10th_percentile": 15542.49, "90th_percentile": 15542.49, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 15388.71, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 21,314.00, and; Pricing Extension - NM HB XR PRC - VWH 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": 15388.71, "10th_percentile": 15388.71, "90th_percentile": 15388.71, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 19895.43, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 27,556.00, and; Pricing Extension - NM HB XR PRC - VWH BCBS PPO STOP LOSS & LESSOR OF 9.1.24; Note: Multiple pricing methods applied. Paid $19,481.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 19481.75, "10th_percentile": 19481.75, "90th_percentile": 19481.75, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 15388.71, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 21,314.00, and; Pricing Extension - NM HB XR PRC - VWH BCBS CHOICE SELECT STOP LOSS & LESSOR OF*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15388.71, "10th_percentile": 15388.71, "90th_percentile": 15388.71, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 15451.52, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 21,401.00, and; Pricing Extension - NM HB XR PRC - VWH 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": 15451.52, "10th_percentile": 15451.52, "90th_percentile": 15451.52, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 15451.52, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 21,401.00, and; Pricing Extension - NM HB XR PRC - VWH 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": 15451.52, "10th_percentile": 15451.52, "90th_percentile": 15451.52, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 19895.43, "standard_charge_algorithm": "Re-evaluated: HLB.764862004; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 27,556.00, and; Pricing Extension - NM HB XR PRC - VWH BCBS PPO STOP LOSS & LESSOR OF 9.1.24; Note: Multiple pricing methods applied. Paid $19,481.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 19481.75, "10th_percentile": 19481.75, "90th_percentile": 19481.75, "count": "1 through 10", "methodology": "case rate" } ] } ] }, { "description": "BIOPSY PUNCH DERMAL 2MM (33-31)", "code_information": [ { "code": "SUP-9063416", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 6.26, "maximum": 32.93, "setting": "outpatient", "gross_charge": 32.93, "discounted_cash": 23.05, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 6.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 6.26, "10th_percentile": 6.26, "90th_percentile": 6.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 28.81, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 28.81, "10th_percentile": 28.81, "90th_percentile": 28.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 22.19, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 22.19, "10th_percentile": 22.19, "90th_percentile": 22.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 26.84, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.84, "10th_percentile": 26.84, "90th_percentile": 26.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 14.92, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.92, "10th_percentile": 14.92, "90th_percentile": 14.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 14.82, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 14.82, "10th_percentile": 14.82, "90th_percentile": 14.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 27.99, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 27.99, "10th_percentile": 27.99, "90th_percentile": 27.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 15.91, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.91, "10th_percentile": 15.91, "90th_percentile": 15.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 21.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 21.45, "10th_percentile": 21.45, "90th_percentile": 21.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 26.34, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 26.34, "10th_percentile": 26.34, "90th_percentile": 26.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 17.9, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% 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; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 24.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 24.7, "10th_percentile": 24.7, "90th_percentile": 24.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 32.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 22.03, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.03, "10th_percentile": 22.03, "90th_percentile": 22.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 16.53, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.53, "10th_percentile": 16.53, "90th_percentile": 16.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 8.36, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 8.36, "10th_percentile": 8.36, "90th_percentile": 8.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 22.82, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.82, "10th_percentile": 22.82, "90th_percentile": 22.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 11.46, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 11.46, "10th_percentile": 11.46, "90th_percentile": 11.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 21.54, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.54, "10th_percentile": 21.54, "90th_percentile": 21.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 32.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 32.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 6.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 6.26, "10th_percentile": 6.26, "90th_percentile": 6.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 6.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 6.26, "10th_percentile": 6.26, "90th_percentile": 6.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 18.41, "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": 18.41, "10th_percentile": 18.41, "90th_percentile": 18.41, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 18.56, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.56, "10th_percentile": 18.56, "90th_percentile": 18.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 22.08, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.08, "10th_percentile": 22.08, "90th_percentile": 22.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 26.84, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.84, "10th_percentile": 26.84, "90th_percentile": 26.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 20.78, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.78, "10th_percentile": 20.78, "90th_percentile": 20.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 21.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 21.45, "10th_percentile": 21.45, "90th_percentile": 21.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "BIT 180114000 3/32 TWST DRILL", "code_information": [ { "code": "SUP-317476", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 134.54, "maximum": 708.1, "setting": "outpatient", "gross_charge": 708.1, "discounted_cash": 495.67, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 708.1, "10th_percentile": 708.1, "90th_percentile": 708.1, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 708.1, "10th_percentile": 708.1, "90th_percentile": 708.1, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 708.1, "10th_percentile": 708.1, "90th_percentile": 708.1, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 708.1, "10th_percentile": 708.1, "90th_percentile": 708.1, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 708.1, "10th_percentile": 708.1, "90th_percentile": 708.1, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 708.1, "10th_percentile": 708.1, "90th_percentile": 708.1, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 134.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 134.54, "10th_percentile": 134.54, "90th_percentile": 134.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 619.59, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 619.59, "10th_percentile": 619.59, "90th_percentile": 619.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 477.26, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 477.26, "10th_percentile": 477.26, "90th_percentile": 477.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 577.1, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 577.1, "10th_percentile": 577.1, "90th_percentile": 577.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 320.77, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 320.77, "10th_percentile": 320.77, "90th_percentile": 320.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 318.65, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 318.65, "10th_percentile": 318.65, "90th_percentile": 318.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 601.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 601.89, "10th_percentile": 601.89, "90th_percentile": 601.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 342.01, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 342.01, "10th_percentile": 342.01, "90th_percentile": 342.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 461.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 461.33, "10th_percentile": 461.33, "90th_percentile": 461.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 566.48, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 566.48, "10th_percentile": 566.48, "90th_percentile": 566.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 384.85, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 384.85, "10th_percentile": 384.85, "90th_percentile": 384.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 531.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 531.08, "10th_percentile": 531.08, "90th_percentile": 531.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 708.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 708.1, "10th_percentile": 708.1, "90th_percentile": 708.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 473.72, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 473.72, "10th_percentile": 473.72, "90th_percentile": 473.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 355.47, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 355.47, "10th_percentile": 355.47, "90th_percentile": 355.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 179.86, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 179.86, "10th_percentile": 179.86, "90th_percentile": 179.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 490.71, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 490.71, "10th_percentile": 490.71, "90th_percentile": 490.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 246.42, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 246.42, "10th_percentile": 246.42, "90th_percentile": 246.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 463.1, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 463.1, "10th_percentile": 463.1, "90th_percentile": 463.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 708.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 708.1, "10th_percentile": 708.1, "90th_percentile": 708.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 708.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 708.1, "10th_percentile": 708.1, "90th_percentile": 708.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 134.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 134.54, "10th_percentile": 134.54, "90th_percentile": 134.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 134.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 134.54, "10th_percentile": 134.54, "90th_percentile": 134.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 395.83, "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": 395.83, "10th_percentile": 395.83, "90th_percentile": 395.83, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 399.01, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 399.01, "10th_percentile": 399.01, "90th_percentile": 399.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 474.85, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 474.85, "10th_percentile": 474.85, "90th_percentile": 474.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 577.1, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 577.1, "10th_percentile": 577.1, "90th_percentile": 577.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 446.88, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 446.88, "10th_percentile": 446.88, "90th_percentile": 446.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 461.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 461.33, "10th_percentile": 461.33, "90th_percentile": 461.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% 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": 105.65, "maximum": 556.06, "setting": "outpatient", "gross_charge": 556.06, "discounted_cash": 389.24, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 556.06, "10th_percentile": 556.06, "90th_percentile": 556.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 556.06, "10th_percentile": 556.06, "90th_percentile": 556.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 556.06, "10th_percentile": 556.06, "90th_percentile": 556.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 556.06, "10th_percentile": 556.06, "90th_percentile": 556.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 556.06, "10th_percentile": 556.06, "90th_percentile": 556.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 556.06, "10th_percentile": 556.06, "90th_percentile": 556.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 105.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 105.65, "10th_percentile": 105.65, "90th_percentile": 105.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 486.55, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 486.55, "10th_percentile": 486.55, "90th_percentile": 486.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 374.78, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 374.78, "10th_percentile": 374.78, "90th_percentile": 374.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 453.19, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 453.19, "10th_percentile": 453.19, "90th_percentile": 453.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 251.9, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 251.9, "10th_percentile": 251.9, "90th_percentile": 251.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 250.23, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 250.23, "10th_percentile": 250.23, "90th_percentile": 250.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 472.65, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 472.65, "10th_percentile": 472.65, "90th_percentile": 472.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 268.58, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 268.58, "10th_percentile": 268.58, "90th_percentile": 268.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 362.27, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 362.27, "10th_percentile": 362.27, "90th_percentile": 362.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 444.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 444.85, "10th_percentile": 444.85, "90th_percentile": 444.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 302.22, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 302.22, "10th_percentile": 302.22, "90th_percentile": 302.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 417.05, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 417.05, "10th_percentile": 417.05, "90th_percentile": 417.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 556.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 556.06, "10th_percentile": 556.06, "90th_percentile": 556.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 372.0, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 372.0, "10th_percentile": 372.0, "90th_percentile": 372.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 279.14, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 279.14, "10th_percentile": 279.14, "90th_percentile": 279.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 141.24, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 141.24, "10th_percentile": 141.24, "90th_percentile": 141.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 385.35, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 385.35, "10th_percentile": 385.35, "90th_percentile": 385.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 193.51, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 193.51, "10th_percentile": 193.51, "90th_percentile": 193.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 363.66, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 363.66, "10th_percentile": 363.66, "90th_percentile": 363.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 556.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 556.06, "10th_percentile": 556.06, "90th_percentile": 556.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 556.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 556.06, "10th_percentile": 556.06, "90th_percentile": 556.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 105.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 105.65, "10th_percentile": 105.65, "90th_percentile": 105.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 105.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 105.65, "10th_percentile": 105.65, "90th_percentile": 105.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 310.84, "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": 310.84, "10th_percentile": 310.84, "90th_percentile": 310.84, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 313.34, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 313.34, "10th_percentile": 313.34, "90th_percentile": 313.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 372.89, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 372.89, "10th_percentile": 372.89, "90th_percentile": 372.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 453.19, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 453.19, "10th_percentile": 453.19, "90th_percentile": 453.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 350.93, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 350.93, "10th_percentile": 350.93, "90th_percentile": 350.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 362.27, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 362.27, "10th_percentile": 362.27, "90th_percentile": 362.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "BIT DRILL TWST 5MM X 1/8IN SS", "code_information": [ { "code": "SUP-333240", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 68.92, "maximum": 362.73, "setting": "outpatient", "gross_charge": 362.73, "discounted_cash": 253.91, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 362.73, "10th_percentile": 362.73, "90th_percentile": 362.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 362.73, "10th_percentile": 362.73, "90th_percentile": 362.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 362.73, "10th_percentile": 362.73, "90th_percentile": 362.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 362.73, "10th_percentile": 362.73, "90th_percentile": 362.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 362.73, "10th_percentile": 362.73, "90th_percentile": 362.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 362.73, "10th_percentile": 362.73, "90th_percentile": 362.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 68.92, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 68.92, "10th_percentile": 68.92, "90th_percentile": 68.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 317.39, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 317.39, "10th_percentile": 317.39, "90th_percentile": 317.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 244.48, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 244.48, "10th_percentile": 244.48, "90th_percentile": 244.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 295.62, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.62, "10th_percentile": 295.62, "90th_percentile": 295.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 164.32, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 164.32, "10th_percentile": 164.32, "90th_percentile": 164.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 163.23, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 163.23, "10th_percentile": 163.23, "90th_percentile": 163.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 308.32, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 308.32, "10th_percentile": 308.32, "90th_percentile": 308.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 175.2, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 175.2, "10th_percentile": 175.2, "90th_percentile": 175.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 236.32, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 236.32, "10th_percentile": 236.32, "90th_percentile": 236.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 290.18, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 290.18, "10th_percentile": 290.18, "90th_percentile": 290.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 197.14, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 197.14, "10th_percentile": 197.14, "90th_percentile": 197.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 272.05, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 272.05, "10th_percentile": 272.05, "90th_percentile": 272.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 362.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 362.73, "10th_percentile": 362.73, "90th_percentile": 362.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 242.67, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 242.67, "10th_percentile": 242.67, "90th_percentile": 242.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 182.09, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.09, "10th_percentile": 182.09, "90th_percentile": 182.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 92.13, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 92.13, "10th_percentile": 92.13, "90th_percentile": 92.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 251.37, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 251.37, "10th_percentile": 251.37, "90th_percentile": 251.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 126.23, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 126.23, "10th_percentile": 126.23, "90th_percentile": 126.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 237.23, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 237.23, "10th_percentile": 237.23, "90th_percentile": 237.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 362.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 362.73, "10th_percentile": 362.73, "90th_percentile": 362.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 362.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 362.73, "10th_percentile": 362.73, "90th_percentile": 362.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 68.92, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 68.92, "10th_percentile": 68.92, "90th_percentile": 68.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 68.92, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 68.92, "10th_percentile": 68.92, "90th_percentile": 68.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 202.77, "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": 202.77, "10th_percentile": 202.77, "90th_percentile": 202.77, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 204.4, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 204.4, "10th_percentile": 204.4, "90th_percentile": 204.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 243.25, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.25, "10th_percentile": 243.25, "90th_percentile": 243.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 295.62, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.62, "10th_percentile": 295.62, "90th_percentile": 295.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 228.92, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 228.92, "10th_percentile": 228.92, "90th_percentile": 228.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 236.32, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 236.32, "10th_percentile": 236.32, "90th_percentile": 236.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "BLANKET INTOP UPPR BDY BAIR HGGR MUL-POSITION 78X24IN", "code_information": [ { "code": "SUP-337798", "type": "CDM" }, { "code": "27103350", "type": "LOCAL" }, { "code": "0271", "type": "RC" } ], "standard_charges": [ { "minimum": 15.74, "maximum": 82.83, "setting": "outpatient", "gross_charge": 82.83, "discounted_cash": 57.98, "payers_information": [ { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 40.01, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 37.52, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.52, "10th_percentile": 37.52, "90th_percentile": 37.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 67.51, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.51, "10th_percentile": 67.51, "90th_percentile": 67.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 53.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 53.96, "10th_percentile": 53.96, "90th_percentile": 53.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 45.02, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 45.02, "10th_percentile": 45.02, "90th_percentile": 45.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 55.83, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 55.83, "10th_percentile": 55.83, "90th_percentile": 55.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 62.12, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 62.12, "10th_percentile": 62.12, "90th_percentile": 62.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 15.74, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 15.74, "10th_percentile": 15.74, "90th_percentile": 15.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 72.48, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 72.48, "10th_percentile": 72.48, "90th_percentile": 72.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 66.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 66.26, "10th_percentile": 66.26, "90th_percentile": 66.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 37.27, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 37.27, "10th_percentile": 37.27, "90th_percentile": 37.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 70.41, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 70.41, "10th_percentile": 70.41, "90th_percentile": 70.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 82.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 55.41, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.41, "10th_percentile": 55.41, "90th_percentile": 55.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 41.58, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.58, "10th_percentile": 41.58, "90th_percentile": 41.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 21.04, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 21.04, "10th_percentile": 21.04, "90th_percentile": 21.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 28.82, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 28.82, "10th_percentile": 28.82, "90th_percentile": 28.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 57.4, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.4, "10th_percentile": 57.4, "90th_percentile": 57.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 54.17, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 54.17, "10th_percentile": 54.17, "90th_percentile": 54.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 82.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 82.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 15.74, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 15.74, "10th_percentile": 15.74, "90th_percentile": 15.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 15.74, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 15.74, "10th_percentile": 15.74, "90th_percentile": 15.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 46.3, "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": 46.3, "10th_percentile": 46.3, "90th_percentile": 46.3, "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": "VWH BCBS HMO", "standard_charge_dollar": 53.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 53.96, "10th_percentile": 53.96, "90th_percentile": 53.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 52.27, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.27, "10th_percentile": 52.27, "90th_percentile": 52.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 55.55, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.55, "10th_percentile": 55.55, "90th_percentile": 55.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 67.51, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.51, "10th_percentile": 67.51, "90th_percentile": 67.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 46.67, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.67, "10th_percentile": 46.67, "90th_percentile": 46.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "BLDE OSTEOTOM BNE THN 8MMX3IN", "code_information": [ { "code": "SUP-144464", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 532.38, "maximum": 2802.0, "setting": "outpatient", "gross_charge": 2802.0, "discounted_cash": 1961.4, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2802.0, "10th_percentile": 2802.0, "90th_percentile": 2802.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2802.0, "10th_percentile": 2802.0, "90th_percentile": 2802.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2802.0, "10th_percentile": 2802.0, "90th_percentile": 2802.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2802.0, "10th_percentile": 2802.0, "90th_percentile": 2802.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2802.0, "10th_percentile": 2802.0, "90th_percentile": 2802.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2802.0, "10th_percentile": 2802.0, "90th_percentile": 2802.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 532.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 532.38, "10th_percentile": 532.38, "90th_percentile": 532.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2451.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2451.75, "10th_percentile": 2451.75, "90th_percentile": 2451.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1888.55, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1888.55, "10th_percentile": 1888.55, "90th_percentile": 1888.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2283.63, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2283.63, "10th_percentile": 2283.63, "90th_percentile": 2283.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1269.31, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1269.31, "10th_percentile": 1269.31, "90th_percentile": 1269.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1260.9, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1260.9, "10th_percentile": 1260.9, "90th_percentile": 1260.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2381.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2381.7, "10th_percentile": 2381.7, "90th_percentile": 2381.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1353.37, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1353.37, "10th_percentile": 1353.37, "90th_percentile": 1353.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1825.5, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1825.5, "10th_percentile": 1825.5, "90th_percentile": 1825.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2241.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2241.6, "10th_percentile": 2241.6, "90th_percentile": 2241.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1522.89, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1522.89, "10th_percentile": 1522.89, "90th_percentile": 1522.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2101.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2101.5, "10th_percentile": 2101.5, "90th_percentile": 2101.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2802.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2802.0, "10th_percentile": 2802.0, "90th_percentile": 2802.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1874.54, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1874.54, "10th_percentile": 1874.54, "90th_percentile": 1874.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1406.6, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1406.6, "10th_percentile": 1406.6, "90th_percentile": 1406.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 711.71, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 711.71, "10th_percentile": 711.71, "90th_percentile": 711.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1941.79, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1941.79, "10th_percentile": 1941.79, "90th_percentile": 1941.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 975.1, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 975.1, "10th_percentile": 975.1, "90th_percentile": 975.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1832.51, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1832.51, "10th_percentile": 1832.51, "90th_percentile": 1832.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2802.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2802.0, "10th_percentile": 2802.0, "90th_percentile": 2802.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2802.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2802.0, "10th_percentile": 2802.0, "90th_percentile": 2802.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 532.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 532.38, "10th_percentile": 532.38, "90th_percentile": 532.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 532.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 532.38, "10th_percentile": 532.38, "90th_percentile": 532.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1566.32, "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": 1566.32, "10th_percentile": 1566.32, "90th_percentile": 1566.32, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1578.93, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1578.93, "10th_percentile": 1578.93, "90th_percentile": 1578.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1879.02, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1879.02, "10th_percentile": 1879.02, "90th_percentile": 1879.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2283.63, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2283.63, "10th_percentile": 2283.63, "90th_percentile": 2283.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1768.34, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1768.34, "10th_percentile": 1768.34, "90th_percentile": 1768.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1825.5, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1825.5, "10th_percentile": 1825.5, "90th_percentile": 1825.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-92831", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-1159-18", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.35, "maximum": 63.0, "setting": "outpatient", "gross_charge": 63.0, "discounted_cash": 44.1, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 11.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 11.97, "10th_percentile": 11.97, "90th_percentile": 11.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 11.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 11.97, "10th_percentile": 11.97, "90th_percentile": 11.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 11.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 11.97, "10th_percentile": 11.97, "90th_percentile": 11.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 39.69, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.69, "10th_percentile": 39.69, "90th_percentile": 39.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 51.47, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.47, "10th_percentile": 51.47, "90th_percentile": 51.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 35.22, "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": 35.22, "10th_percentile": 35.22, "90th_percentile": 35.22, "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": "VWH BCBS HMO", "standard_charge_dollar": 41.04, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 41.04, "10th_percentile": 41.04, "90th_percentile": 41.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.05, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.05, "10th_percentile": 38.05, "90th_percentile": 38.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 38.05, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.05, "10th_percentile": 38.05, "90th_percentile": 38.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 63.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 63.0, "10th_percentile": 63.0, "90th_percentile": 63.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 63.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 63.0, "10th_percentile": 63.0, "90th_percentile": 63.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 53.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 53.55, "10th_percentile": 53.55, "90th_percentile": 53.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 55.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 55.13, "10th_percentile": 55.13, "90th_percentile": 55.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 16.0, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 63.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 63.0, "10th_percentile": 63.0, "90th_percentile": 63.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 28.35, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 28.35, "10th_percentile": 28.35, "90th_percentile": 28.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 50.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% 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 Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 41.04, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 41.04, "10th_percentile": 41.04, "90th_percentile": 41.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 34.24, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 34.24, "10th_percentile": 34.24, "90th_percentile": 34.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 42.46, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 42.46, "10th_percentile": 42.46, "90th_percentile": 42.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 47.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 47.25, "10th_percentile": 47.25, "90th_percentile": 47.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 51.47, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.47, "10th_percentile": 51.47, "90th_percentile": 51.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 21.92, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 21.92, "10th_percentile": 21.92, "90th_percentile": 21.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "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": 5.33, "maximum": 77.25, "setting": "outpatient", "gross_charge": 77.25, "discounted_cash": 54.07, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 14.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 14.68, "10th_percentile": 14.68, "90th_percentile": 14.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 14.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 14.68, "10th_percentile": 14.68, "90th_percentile": 14.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 14.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 14.68, "10th_percentile": 14.68, "90th_percentile": 14.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 48.67, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.67, "10th_percentile": 48.67, "90th_percentile": 48.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 63.11, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 43.18, "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": 43.18, "10th_percentile": 43.18, "90th_percentile": 43.18, "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": "VWH BCBS HMO", "standard_charge_dollar": 50.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 50.33, "10th_percentile": 50.33, "90th_percentile": 50.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 46.66, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.66, "10th_percentile": 46.66, "90th_percentile": 46.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 46.66, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.66, "10th_percentile": 46.66, "90th_percentile": 46.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 77.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 77.25, "10th_percentile": 77.25, "90th_percentile": 77.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 77.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 77.25, "10th_percentile": 77.25, "90th_percentile": 77.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 65.66, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 65.66, "10th_percentile": 65.66, "90th_percentile": 65.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 67.59, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 67.59, "10th_percentile": 67.59, "90th_percentile": 67.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 19.62, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 19.62, "10th_percentile": 19.62, "90th_percentile": 19.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 77.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 77.25, "10th_percentile": 77.25, "90th_percentile": 77.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 34.76, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 34.76, "10th_percentile": 34.76, "90th_percentile": 34.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 61.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 61.8, "10th_percentile": 61.8, "90th_percentile": 61.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 50.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 50.33, "10th_percentile": 50.33, "90th_percentile": 50.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 41.99, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 41.99, "10th_percentile": 41.99, "90th_percentile": 41.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 52.07, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 52.07, "10th_percentile": 52.07, "90th_percentile": 52.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 57.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 57.94, "10th_percentile": 57.94, "90th_percentile": 57.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 63.11, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 26.88, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 26.88, "10th_percentile": 26.88, "90th_percentile": 26.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.33, "10th_percentile": 5.33, "90th_percentile": 5.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.33, "10th_percentile": 5.33, "90th_percentile": 5.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.33, "10th_percentile": 5.33, "90th_percentile": 5.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.33, "10th_percentile": 5.33, "90th_percentile": 5.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.33, "10th_percentile": 5.33, "90th_percentile": 5.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.33, "10th_percentile": 5.33, "90th_percentile": 5.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-92830", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00409-9042-16", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.7, "maximum": 35.25, "setting": "outpatient", "gross_charge": 35.25, "discounted_cash": 24.67, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 35.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 35.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 23.05, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.05, "10th_percentile": 23.05, "90th_percentile": 23.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 24.43, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.43, "10th_percentile": 24.43, "90th_percentile": 24.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 12.27, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 12.27, "10th_percentile": 12.27, "90th_percentile": 12.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 8.95, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 8.95, "10th_percentile": 8.95, "90th_percentile": 8.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 6.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 6.7, "10th_percentile": 6.7, "90th_percentile": 6.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 22.97, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 22.97, "10th_percentile": 22.97, "90th_percentile": 22.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 28.73, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.73, "10th_percentile": 28.73, "90th_percentile": 28.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 6.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 6.7, "10th_percentile": 6.7, "90th_percentile": 6.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 23.64, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.64, "10th_percentile": 23.64, "90th_percentile": 23.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 22.25, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.25, "10th_percentile": 22.25, "90th_percentile": 22.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 19.86, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.86, "10th_percentile": 19.86, "90th_percentile": 19.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 22.97, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 22.97, "10th_percentile": 22.97, "90th_percentile": 22.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 19.7, "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": 19.7, "10th_percentile": 19.7, "90th_percentile": 19.7, "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": "VWH BCBS PPO", "standard_charge_dollar": 28.73, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.73, "10th_percentile": 28.73, "90th_percentile": 28.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 23.76, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 23.76, "10th_percentile": 23.76, "90th_percentile": 23.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 15.97, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.97, "10th_percentile": 15.97, "90th_percentile": 15.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 17.03, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.03, "10th_percentile": 17.03, "90th_percentile": 17.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 6.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 6.7, "10th_percentile": 6.7, "90th_percentile": 6.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 29.96, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 29.96, "10th_percentile": 29.96, "90th_percentile": 29.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 15.86, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 15.86, "10th_percentile": 15.86, "90th_percentile": 15.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 26.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 26.44, "10th_percentile": 26.44, "90th_percentile": 26.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 30.84, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 30.84, "10th_percentile": 30.84, "90th_percentile": 30.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 28.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 28.2, "10th_percentile": 28.2, "90th_percentile": 28.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 19.16, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 19.16, "10th_percentile": 19.16, "90th_percentile": 19.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 17.7, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.7, "10th_percentile": 17.7, "90th_percentile": 17.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 23.58, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.58, "10th_percentile": 23.58, "90th_percentile": 23.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 35.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "BUPRENORPHINE HCL 2 MG SL SUBL", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-92462", "type": "CDM" }, { "code": "J0571", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "62756-0459-83", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.95, "maximum": 13.75, "setting": "outpatient", "gross_charge": 13.75, "discounted_cash": 9.62, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 4.79, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 4.79, "10th_percentile": 4.79, "90th_percentile": 4.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.49, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 3.49, "10th_percentile": 3.49, "90th_percentile": 3.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 2.61, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2.61, "10th_percentile": 2.61, "90th_percentile": 2.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 8.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 8.96, "10th_percentile": 8.96, "90th_percentile": 8.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 11.23, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.23, "10th_percentile": 11.23, "90th_percentile": 11.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 2.61, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2.61, "10th_percentile": 2.61, "90th_percentile": 2.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.31, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.31, "10th_percentile": 8.31, "90th_percentile": 8.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8.66, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.66, "10th_percentile": 8.66, "90th_percentile": 8.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8.31, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.31, "10th_percentile": 8.31, "90th_percentile": 8.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 8.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 8.96, "10th_percentile": 8.96, "90th_percentile": 8.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7.69, "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": 7.69, "10th_percentile": 7.69, "90th_percentile": 7.69, "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": "VWH BCBS PPO", "standard_charge_dollar": 11.23, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.23, "10th_percentile": 11.23, "90th_percentile": 11.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual 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": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.95, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 9.27, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 9.27, "10th_percentile": 9.27, "90th_percentile": 9.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.95, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.95, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.95, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2.61, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2.61, "10th_percentile": 2.61, "90th_percentile": 2.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.95, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 11.69, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 11.69, "10th_percentile": 11.69, "90th_percentile": 11.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 6.19, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 6.19, "10th_percentile": 6.19, "90th_percentile": 6.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 10.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 10.31, "10th_percentile": 10.31, "90th_percentile": 10.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.95, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 12.03, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 12.03, "10th_percentile": 12.03, "90th_percentile": 12.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 11.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% 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 Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 7.47, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 7.47, "10th_percentile": 7.47, "90th_percentile": 7.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 6.9, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.9, "10th_percentile": 6.9, "90th_percentile": 6.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 9.2, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.2, "10th_percentile": 9.2, "90th_percentile": 9.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 13.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 13.75, "10th_percentile": 13.75, "90th_percentile": 13.75, "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": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.75, "10th_percentile": 13.75, "90th_percentile": 13.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.75, "10th_percentile": 13.75, "90th_percentile": 13.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% 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": 2.38, "maximum": 12.5, "setting": "outpatient", "gross_charge": 12.5, "discounted_cash": 8.75, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 2.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2.38, "10th_percentile": 2.38, "90th_percentile": 2.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 10.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% 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 Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 6.04, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.04, "10th_percentile": 6.04, "90th_percentile": 6.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 5.66, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.66, "10th_percentile": 5.66, "90th_percentile": 5.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 9.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 9.38, "10th_percentile": 9.38, "90th_percentile": 9.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 5.63, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 5.63, "10th_percentile": 5.63, "90th_percentile": 5.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 8.14, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 8.14, "10th_percentile": 8.14, "90th_percentile": 8.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 10.94, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 10.94, "10th_percentile": 10.94, "90th_percentile": 10.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 8.43, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 8.43, "10th_percentile": 8.43, "90th_percentile": 8.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 10.19, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.19, "10th_percentile": 10.19, "90th_percentile": 10.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 10.63, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 10.63, "10th_percentile": 10.63, "90th_percentile": 10.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 6.79, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 6.79, "10th_percentile": 6.79, "90th_percentile": 6.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 6.28, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.28, "10th_percentile": 6.28, "90th_percentile": 6.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 12.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 12.5, "10th_percentile": 12.5, "90th_percentile": 12.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 8.36, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.36, "10th_percentile": 8.36, "90th_percentile": 8.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 8.66, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.66, "10th_percentile": 8.66, "90th_percentile": 8.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.18, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 3.18, "10th_percentile": 3.18, "90th_percentile": 3.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 4.35, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 8.18, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.18, "10th_percentile": 8.18, "90th_percentile": 8.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 2.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "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; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "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; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.5, "10th_percentile": 12.5, "90th_percentile": 12.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.5, "10th_percentile": 12.5, "90th_percentile": 12.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7.04, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.89, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.89, "10th_percentile": 7.89, "90th_percentile": 7.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 8.14, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 8.14, "10th_percentile": 8.14, "90th_percentile": 8.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 10.19, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.19, "10th_percentile": 10.19, "90th_percentile": 10.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.99, "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": 6.99, "10th_percentile": 6.99, "90th_percentile": 6.99, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.5, "10th_percentile": 12.5, "90th_percentile": 12.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.5, "10th_percentile": 12.5, "90th_percentile": 12.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.5, "10th_percentile": 12.5, "90th_percentile": 12.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.5, "10th_percentile": 12.5, "90th_percentile": 12.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.5, "10th_percentile": 12.5, "90th_percentile": 12.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.5, "10th_percentile": 12.5, "90th_percentile": 12.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BUR RETRACT RND ARTHRO HL 8 FLUTED 5MMX18CM", "code_information": [ { "code": "SUP-356719", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 173.45, "maximum": 912.91, "setting": "outpatient", "gross_charge": 912.91, "discounted_cash": 639.04, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 912.91, "10th_percentile": 912.91, "90th_percentile": 912.91, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 912.91, "10th_percentile": 912.91, "90th_percentile": 912.91, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 912.91, "10th_percentile": 912.91, "90th_percentile": 912.91, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 912.91, "10th_percentile": 912.91, "90th_percentile": 912.91, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 912.91, "10th_percentile": 912.91, "90th_percentile": 912.91, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 912.91, "10th_percentile": 912.91, "90th_percentile": 912.91, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 173.45, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 173.45, "10th_percentile": 173.45, "90th_percentile": 173.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 798.8, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 798.8, "10th_percentile": 798.8, "90th_percentile": 798.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 615.3, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 615.3, "10th_percentile": 615.3, "90th_percentile": 615.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 744.02, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 744.02, "10th_percentile": 744.02, "90th_percentile": 744.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 413.55, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 413.55, "10th_percentile": 413.55, "90th_percentile": 413.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 410.81, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 410.81, "10th_percentile": 410.81, "90th_percentile": 410.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 775.97, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 775.97, "10th_percentile": 775.97, "90th_percentile": 775.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 440.94, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 440.94, "10th_percentile": 440.94, "90th_percentile": 440.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 594.76, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 594.76, "10th_percentile": 594.76, "90th_percentile": 594.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 730.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 730.33, "10th_percentile": 730.33, "90th_percentile": 730.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 496.17, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 496.17, "10th_percentile": 496.17, "90th_percentile": 496.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 684.68, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 684.68, "10th_percentile": 684.68, "90th_percentile": 684.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 912.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 912.91, "10th_percentile": 912.91, "90th_percentile": 912.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 610.74, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 610.74, "10th_percentile": 610.74, "90th_percentile": 610.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 458.28, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.28, "10th_percentile": 458.28, "90th_percentile": 458.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 231.88, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 231.88, "10th_percentile": 231.88, "90th_percentile": 231.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 632.65, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 632.65, "10th_percentile": 632.65, "90th_percentile": 632.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 317.69, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 317.69, "10th_percentile": 317.69, "90th_percentile": 317.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 597.04, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 597.04, "10th_percentile": 597.04, "90th_percentile": 597.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 912.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 912.91, "10th_percentile": 912.91, "90th_percentile": 912.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 912.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 912.91, "10th_percentile": 912.91, "90th_percentile": 912.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 173.45, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "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; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 173.45, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "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; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 510.32, "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": 510.32, "10th_percentile": 510.32, "90th_percentile": 510.32, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 514.42, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 514.42, "10th_percentile": 514.42, "90th_percentile": 514.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 612.2, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 612.2, "10th_percentile": 612.2, "90th_percentile": 612.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 744.02, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 744.02, "10th_percentile": 744.02, "90th_percentile": 744.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 576.14, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 576.14, "10th_percentile": 576.14, "90th_percentile": 576.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 594.76, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 594.76, "10th_percentile": 594.76, "90th_percentile": 594.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "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": 144.26, "maximum": 759.25, "setting": "outpatient", "gross_charge": 759.25, "discounted_cash": 531.47, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 759.25, "10th_percentile": 759.25, "90th_percentile": 759.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 759.25, "10th_percentile": 759.25, "90th_percentile": 759.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 759.25, "10th_percentile": 759.25, "90th_percentile": 759.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 759.25, "10th_percentile": 759.25, "90th_percentile": 759.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 759.25, "10th_percentile": 759.25, "90th_percentile": 759.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 759.25, "10th_percentile": 759.25, "90th_percentile": 759.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 144.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 144.26, "10th_percentile": 144.26, "90th_percentile": 144.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 664.34, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 664.34, "10th_percentile": 664.34, "90th_percentile": 664.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 511.73, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 511.73, "10th_percentile": 511.73, "90th_percentile": 511.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 618.79, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 618.79, "10th_percentile": 618.79, "90th_percentile": 618.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 343.94, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 343.94, "10th_percentile": 343.94, "90th_percentile": 343.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 341.66, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 341.66, "10th_percentile": 341.66, "90th_percentile": 341.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 645.36, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 645.36, "10th_percentile": 645.36, "90th_percentile": 645.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 366.72, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 366.72, "10th_percentile": 366.72, "90th_percentile": 366.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 494.65, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 494.65, "10th_percentile": 494.65, "90th_percentile": 494.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 607.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 607.4, "10th_percentile": 607.4, "90th_percentile": 607.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 412.65, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 412.65, "10th_percentile": 412.65, "90th_percentile": 412.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 569.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 569.44, "10th_percentile": 569.44, "90th_percentile": 569.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 759.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 759.25, "10th_percentile": 759.25, "90th_percentile": 759.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 507.94, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 507.94, "10th_percentile": 507.94, "90th_percentile": 507.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 381.14, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381.14, "10th_percentile": 381.14, "90th_percentile": 381.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 192.85, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 192.85, "10th_percentile": 192.85, "90th_percentile": 192.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 526.16, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 526.16, "10th_percentile": 526.16, "90th_percentile": 526.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 264.22, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 264.22, "10th_percentile": 264.22, "90th_percentile": 264.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 496.55, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 496.55, "10th_percentile": 496.55, "90th_percentile": 496.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 759.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 759.25, "10th_percentile": 759.25, "90th_percentile": 759.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 759.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 759.25, "10th_percentile": 759.25, "90th_percentile": 759.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 144.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 144.26, "10th_percentile": 144.26, "90th_percentile": 144.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 144.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 144.26, "10th_percentile": 144.26, "90th_percentile": 144.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 424.42, "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": 424.42, "10th_percentile": 424.42, "90th_percentile": 424.42, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 427.84, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 427.84, "10th_percentile": 427.84, "90th_percentile": 427.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 509.15, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 509.15, "10th_percentile": 509.15, "90th_percentile": 509.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 618.79, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 618.79, "10th_percentile": 618.79, "90th_percentile": 618.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 479.16, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 479.16, "10th_percentile": 479.16, "90th_percentile": 479.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 494.65, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 494.65, "10th_percentile": 494.65, "90th_percentile": 494.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "BURR 4MM ROUND AR-8400RBE", "code_information": [ { "code": "SUP-317725", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 149.77, "maximum": 788.26, "setting": "outpatient", "gross_charge": 788.26, "discounted_cash": 551.78, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 149.77, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 149.77, "10th_percentile": 149.77, "90th_percentile": 149.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 689.73, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 689.73, "10th_percentile": 689.73, "90th_percentile": 689.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 531.29, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 531.29, "10th_percentile": 531.29, "90th_percentile": 531.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 642.43, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 642.43, "10th_percentile": 642.43, "90th_percentile": 642.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 357.08, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 357.08, "10th_percentile": 357.08, "90th_percentile": 357.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 354.72, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 354.72, "10th_percentile": 354.72, "90th_percentile": 354.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 670.02, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 670.02, "10th_percentile": 670.02, "90th_percentile": 670.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 380.73, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 380.73, "10th_percentile": 380.73, "90th_percentile": 380.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 513.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 513.55, "10th_percentile": 513.55, "90th_percentile": 513.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 630.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 630.61, "10th_percentile": 630.61, "90th_percentile": 630.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 428.42, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 428.42, "10th_percentile": 428.42, "90th_percentile": 428.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 591.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 591.2, "10th_percentile": 591.2, "90th_percentile": 591.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 788.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 527.35, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 527.35, "10th_percentile": 527.35, "90th_percentile": 527.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 395.71, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 395.71, "10th_percentile": 395.71, "90th_percentile": 395.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 200.22, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 200.22, "10th_percentile": 200.22, "90th_percentile": 200.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 546.26, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 546.26, "10th_percentile": 546.26, "90th_percentile": 546.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 274.31, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 274.31, "10th_percentile": 274.31, "90th_percentile": 274.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 515.52, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 515.52, "10th_percentile": 515.52, "90th_percentile": 515.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 788.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 788.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 149.77, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 149.77, "10th_percentile": 149.77, "90th_percentile": 149.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 149.77, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 149.77, "10th_percentile": 149.77, "90th_percentile": 149.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 440.64, "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": 440.64, "10th_percentile": 440.64, "90th_percentile": 440.64, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 444.18, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 444.18, "10th_percentile": 444.18, "90th_percentile": 444.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 528.61, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 528.61, "10th_percentile": 528.61, "90th_percentile": 528.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 642.43, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 642.43, "10th_percentile": 642.43, "90th_percentile": 642.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 497.47, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 497.47, "10th_percentile": 497.47, "90th_percentile": 497.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 513.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 513.55, "10th_percentile": 513.55, "90th_percentile": 513.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "BURR ROUND 8 FLUTE 5.5MMX13CM", "code_information": [ { "code": "SUP-317276", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 149.77, "maximum": 788.26, "setting": "outpatient", "gross_charge": 788.26, "discounted_cash": 551.78, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 149.77, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 149.77, "10th_percentile": 149.77, "90th_percentile": 149.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 689.73, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 689.73, "10th_percentile": 689.73, "90th_percentile": 689.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 531.29, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 531.29, "10th_percentile": 531.29, "90th_percentile": 531.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 642.43, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 642.43, "10th_percentile": 642.43, "90th_percentile": 642.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 357.08, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 357.08, "10th_percentile": 357.08, "90th_percentile": 357.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 354.72, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 354.72, "10th_percentile": 354.72, "90th_percentile": 354.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 670.02, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 670.02, "10th_percentile": 670.02, "90th_percentile": 670.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 380.73, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 380.73, "10th_percentile": 380.73, "90th_percentile": 380.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 513.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 513.55, "10th_percentile": 513.55, "90th_percentile": 513.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 630.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 630.61, "10th_percentile": 630.61, "90th_percentile": 630.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 428.42, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 428.42, "10th_percentile": 428.42, "90th_percentile": 428.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 591.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 591.2, "10th_percentile": 591.2, "90th_percentile": 591.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 788.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 527.35, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 527.35, "10th_percentile": 527.35, "90th_percentile": 527.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 395.71, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 395.71, "10th_percentile": 395.71, "90th_percentile": 395.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 200.22, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 200.22, "10th_percentile": 200.22, "90th_percentile": 200.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 546.26, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 546.26, "10th_percentile": 546.26, "90th_percentile": 546.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 274.31, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 274.31, "10th_percentile": 274.31, "90th_percentile": 274.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 515.52, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 515.52, "10th_percentile": 515.52, "90th_percentile": 515.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 788.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 788.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 788.26, "10th_percentile": 788.26, "90th_percentile": 788.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 149.77, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 149.77, "10th_percentile": 149.77, "90th_percentile": 149.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 149.77, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 149.77, "10th_percentile": 149.77, "90th_percentile": 149.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 440.64, "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": 440.64, "10th_percentile": 440.64, "90th_percentile": 440.64, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 444.18, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 444.18, "10th_percentile": 444.18, "90th_percentile": 444.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 528.61, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 528.61, "10th_percentile": 528.61, "90th_percentile": 528.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 642.43, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 642.43, "10th_percentile": 642.43, "90th_percentile": 642.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 497.47, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 497.47, "10th_percentile": 497.47, "90th_percentile": 497.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 513.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 513.55, "10th_percentile": 513.55, "90th_percentile": 513.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "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": 32185.98, "maximum": 466463.5, "setting": "outpatient", "gross_charge": 466463.5, "discounted_cash": 326524.44, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 88628.07, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 88628.07, "10th_percentile": 88628.07, "90th_percentile": 88628.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 88628.07, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 88628.07, "10th_percentile": 88628.07, "90th_percentile": 88628.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 88628.07, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 88628.07, "10th_percentile": 88628.07, "90th_percentile": 88628.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 293872.0, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 293872.0, "10th_percentile": 293872.0, "90th_percentile": 293872.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 381100.7, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381100.7, "10th_percentile": 381100.7, "90th_percentile": 381100.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 260753.1, "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": 260753.1, "10th_percentile": 260753.1, "90th_percentile": 260753.1, "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": "VWH BCBS HMO", "standard_charge_dollar": 303900.97, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 303900.97, "10th_percentile": 303900.97, "90th_percentile": 303900.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 281743.94, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 281743.94, "10th_percentile": 281743.94, "90th_percentile": 281743.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 281743.94, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 281743.94, "10th_percentile": 281743.94, "90th_percentile": 281743.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466463.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466463.5, "10th_percentile": 466463.5, "90th_percentile": 466463.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466463.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466463.5, "10th_percentile": 466463.5, "90th_percentile": 466463.5, "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": "VWH HFN", "standard_charge_dollar": 396493.97, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 396493.97, "10th_percentile": 396493.97, "90th_percentile": 396493.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 408155.56, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 408155.56, "10th_percentile": 408155.56, "90th_percentile": 408155.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 466463.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 466463.5, "10th_percentile": 466463.5, "90th_percentile": 466463.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 209908.58, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 209908.58, "10th_percentile": 209908.58, "90th_percentile": 209908.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 373170.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 373170.8, "10th_percentile": 373170.8, "90th_percentile": 373170.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 303900.97, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 303900.97, "10th_percentile": 303900.97, "90th_percentile": 303900.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 253522.9, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 253522.9, "10th_percentile": 253522.9, "90th_percentile": 253522.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 381100.7, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381100.7, "10th_percentile": 381100.7, "90th_percentile": 381100.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32185.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32185.98, "10th_percentile": 32185.98, "90th_percentile": 32185.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32185.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32185.98, "10th_percentile": 32185.98, "90th_percentile": 32185.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32185.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32185.98, "10th_percentile": 32185.98, "90th_percentile": 32185.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32185.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32185.98, "10th_percentile": 32185.98, "90th_percentile": 32185.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32185.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32185.98, "10th_percentile": 32185.98, "90th_percentile": 32185.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32185.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32185.98, "10th_percentile": 32185.98, "90th_percentile": 32185.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_algorithm": "No contract line matched", "median_amount": 466463.5, "10th_percentile": 466463.5, "90th_percentile": 466463.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_algorithm": "No contract line matched", "median_amount": 466463.5, "10th_percentile": 466463.5, "90th_percentile": 466463.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_algorithm": "No contract line matched", "median_amount": 466463.5, "10th_percentile": 466463.5, "90th_percentile": 466463.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_algorithm": "No contract line matched", "median_amount": 466463.5, "10th_percentile": 466463.5, "90th_percentile": 466463.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "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": 20.13, "maximum": 291.75, "setting": "outpatient", "gross_charge": 291.75, "discounted_cash": 204.22, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 55.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 55.43, "10th_percentile": 55.43, "90th_percentile": 55.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 55.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 55.43, "10th_percentile": 55.43, "90th_percentile": 55.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 55.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 55.43, "10th_percentile": 55.43, "90th_percentile": 55.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 183.8, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 183.8, "10th_percentile": 183.8, "90th_percentile": 183.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 238.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 238.36, "10th_percentile": 238.36, "90th_percentile": 238.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 163.09, "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": 163.09, "10th_percentile": 163.09, "90th_percentile": 163.09, "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": "VWH BCBS HMO", "standard_charge_dollar": 190.08, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 190.08, "10th_percentile": 190.08, "90th_percentile": 190.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 176.22, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.22, "10th_percentile": 176.22, "90th_percentile": 176.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 176.22, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.22, "10th_percentile": 176.22, "90th_percentile": 176.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 291.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 291.75, "10th_percentile": 291.75, "90th_percentile": 291.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 291.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 291.75, "10th_percentile": 291.75, "90th_percentile": 291.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 247.99, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 247.99, "10th_percentile": 247.99, "90th_percentile": 247.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 255.28, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 255.28, "10th_percentile": 255.28, "90th_percentile": 255.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 74.1, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 74.1, "10th_percentile": 74.1, "90th_percentile": 74.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 291.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 291.75, "10th_percentile": 291.75, "90th_percentile": 291.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 131.29, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 131.29, "10th_percentile": 131.29, "90th_percentile": 131.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 233.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 233.4, "10th_percentile": 233.4, "90th_percentile": 233.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 190.08, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 190.08, "10th_percentile": 190.08, "90th_percentile": 190.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 158.57, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 158.57, "10th_percentile": 158.57, "90th_percentile": 158.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 196.64, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 196.64, "10th_percentile": 196.64, "90th_percentile": 196.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 218.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 218.81, "10th_percentile": 218.81, "90th_percentile": 218.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 238.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 238.36, "10th_percentile": 238.36, "90th_percentile": 238.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 101.53, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 101.53, "10th_percentile": 101.53, "90th_percentile": 101.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.13, "10th_percentile": 20.13, "90th_percentile": 20.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.13, "10th_percentile": 20.13, "90th_percentile": 20.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.13, "10th_percentile": 20.13, "90th_percentile": 20.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.13, "10th_percentile": 20.13, "90th_percentile": 20.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.13, "10th_percentile": 20.13, "90th_percentile": 20.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.13, "10th_percentile": 20.13, "90th_percentile": 20.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CALCIUM CARBONATE 200 MG CALCIUM (500 MG) ORAL CHEW", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9385", "type": "CDM" }, { "code": "J8499", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "00536-1007-15", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 2.25, "setting": "outpatient", "gross_charge": 2.25, "discounted_cash": 1.57, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 0.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.42, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.42, "10th_percentile": 1.42, "90th_percentile": 1.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.36, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.26, "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": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "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": "VWH BCBS PPO", "standard_charge_dollar": 1.84, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.84, "10th_percentile": 1.84, "90th_percentile": 1.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1.91, "10th_percentile": 1.91, "90th_percentile": 1.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1.01, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1.01, "10th_percentile": 1.01, "90th_percentile": 1.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1.97, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1.22, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.57, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 0.57, "10th_percentile": 0.57, "90th_percentile": 0.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.84, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.84, "10th_percentile": 1.84, "90th_percentile": 1.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.36, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "CANISTER THER WND NEG PRSS UN", "code_information": [ { "code": "SUP-300837", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 26.27, "maximum": 138.28, "setting": "outpatient", "gross_charge": 138.28, "discounted_cash": 96.8, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 26.27, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 121.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 121.0, "10th_percentile": 121.0, "90th_percentile": 121.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 93.2, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 93.2, "10th_percentile": 93.2, "90th_percentile": 93.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 112.7, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.7, "10th_percentile": 112.7, "90th_percentile": 112.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 62.64, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.64, "10th_percentile": 62.64, "90th_percentile": 62.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 62.23, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 62.23, "10th_percentile": 62.23, "90th_percentile": 62.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 117.54, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 117.54, "10th_percentile": 117.54, "90th_percentile": 117.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 66.79, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.79, "10th_percentile": 66.79, "90th_percentile": 66.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 90.09, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 90.09, "10th_percentile": 90.09, "90th_percentile": 90.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 110.62, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 110.62, "10th_percentile": 110.62, "90th_percentile": 110.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 75.16, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 75.16, "10th_percentile": 75.16, "90th_percentile": 75.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 103.71, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 103.71, "10th_percentile": 103.71, "90th_percentile": 103.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 138.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 92.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.51, "10th_percentile": 92.51, "90th_percentile": 92.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 69.42, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 69.42, "10th_percentile": 69.42, "90th_percentile": 69.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 35.12, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 35.12, "10th_percentile": 35.12, "90th_percentile": 35.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 95.83, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95.83, "10th_percentile": 95.83, "90th_percentile": 95.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 48.12, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 48.12, "10th_percentile": 48.12, "90th_percentile": 48.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 90.44, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.44, "10th_percentile": 90.44, "90th_percentile": 90.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 138.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 138.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 26.27, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 26.27, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 77.3, "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": 77.3, "10th_percentile": 77.3, "90th_percentile": 77.3, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 77.92, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.92, "10th_percentile": 77.92, "90th_percentile": 77.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 92.73, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.73, "10th_percentile": 92.73, "90th_percentile": 92.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 112.7, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.7, "10th_percentile": 112.7, "90th_percentile": 112.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 87.27, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.27, "10th_percentile": 87.27, "90th_percentile": 87.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 90.09, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 90.09, "10th_percentile": 90.09, "90th_percentile": 90.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "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": 90.49, "maximum": 476.27, "setting": "outpatient", "gross_charge": 476.27, "discounted_cash": 333.39, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.27, "10th_percentile": 476.27, "90th_percentile": 476.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.27, "10th_percentile": 476.27, "90th_percentile": 476.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.27, "10th_percentile": 476.27, "90th_percentile": 476.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.27, "10th_percentile": 476.27, "90th_percentile": 476.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.27, "10th_percentile": 476.27, "90th_percentile": 476.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.27, "10th_percentile": 476.27, "90th_percentile": 476.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 90.49, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 90.49, "10th_percentile": 90.49, "90th_percentile": 90.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 416.74, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 416.74, "10th_percentile": 416.74, "90th_percentile": 416.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 321.01, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 321.01, "10th_percentile": 321.01, "90th_percentile": 321.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 388.16, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 388.16, "10th_percentile": 388.16, "90th_percentile": 388.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 215.75, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.75, "10th_percentile": 215.75, "90th_percentile": 215.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 214.32, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 214.32, "10th_percentile": 214.32, "90th_percentile": 214.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 404.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 404.83, "10th_percentile": 404.83, "90th_percentile": 404.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 230.04, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 230.04, "10th_percentile": 230.04, "90th_percentile": 230.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 310.29, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 310.29, "10th_percentile": 310.29, "90th_percentile": 310.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 381.02, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 381.02, "10th_percentile": 381.02, "90th_percentile": 381.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 258.85, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 258.85, "10th_percentile": 258.85, "90th_percentile": 258.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 357.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 357.2, "10th_percentile": 357.2, "90th_percentile": 357.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 476.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 476.27, "10th_percentile": 476.27, "90th_percentile": 476.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 318.62, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 318.62, "10th_percentile": 318.62, "90th_percentile": 318.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 239.09, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.09, "10th_percentile": 239.09, "90th_percentile": 239.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 120.97, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 120.97, "10th_percentile": 120.97, "90th_percentile": 120.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 330.06, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 330.06, "10th_percentile": 330.06, "90th_percentile": 330.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 165.74, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 165.74, "10th_percentile": 165.74, "90th_percentile": 165.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 311.48, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 311.48, "10th_percentile": 311.48, "90th_percentile": 311.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 476.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 476.27, "10th_percentile": 476.27, "90th_percentile": 476.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 476.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 476.27, "10th_percentile": 476.27, "90th_percentile": 476.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 90.49, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 90.49, "10th_percentile": 90.49, "90th_percentile": 90.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 90.49, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 90.49, "10th_percentile": 90.49, "90th_percentile": 90.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 266.23, "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": 266.23, "10th_percentile": 266.23, "90th_percentile": 266.23, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 268.38, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 268.38, "10th_percentile": 268.38, "90th_percentile": 268.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 319.39, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 319.39, "10th_percentile": 319.39, "90th_percentile": 319.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 388.16, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 388.16, "10th_percentile": 388.16, "90th_percentile": 388.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 300.57, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 300.57, "10th_percentile": 300.57, "90th_percentile": 300.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 310.29, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 310.29, "10th_percentile": 310.29, "90th_percentile": 310.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "CANNULA THREADED 8.25X7CM AR-6530", "code_information": [ { "code": "SUP-9054341", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 69.81, "maximum": 367.41, "setting": "outpatient", "gross_charge": 367.41, "discounted_cash": 257.19, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 367.41, "10th_percentile": 367.41, "90th_percentile": 367.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 367.41, "10th_percentile": 367.41, "90th_percentile": 367.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 367.41, "10th_percentile": 367.41, "90th_percentile": 367.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 367.41, "10th_percentile": 367.41, "90th_percentile": 367.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 367.41, "10th_percentile": 367.41, "90th_percentile": 367.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 367.41, "10th_percentile": 367.41, "90th_percentile": 367.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 69.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 69.81, "10th_percentile": 69.81, "90th_percentile": 69.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 321.48, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 321.48, "10th_percentile": 321.48, "90th_percentile": 321.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 247.63, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 247.63, "10th_percentile": 247.63, "90th_percentile": 247.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 299.44, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 299.44, "10th_percentile": 299.44, "90th_percentile": 299.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 166.44, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 166.44, "10th_percentile": 166.44, "90th_percentile": 166.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 165.33, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 165.33, "10th_percentile": 165.33, "90th_percentile": 165.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 312.3, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 312.3, "10th_percentile": 312.3, "90th_percentile": 312.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 177.46, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.46, "10th_percentile": 177.46, "90th_percentile": 177.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 239.37, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 239.37, "10th_percentile": 239.37, "90th_percentile": 239.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 293.93, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 293.93, "10th_percentile": 293.93, "90th_percentile": 293.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 199.69, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 199.69, "10th_percentile": 199.69, "90th_percentile": 199.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 275.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 275.56, "10th_percentile": 275.56, "90th_percentile": 275.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 367.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 367.41, "10th_percentile": 367.41, "90th_percentile": 367.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 245.8, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.8, "10th_percentile": 245.8, "90th_percentile": 245.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 184.44, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 184.44, "10th_percentile": 184.44, "90th_percentile": 184.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 93.32, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 93.32, "10th_percentile": 93.32, "90th_percentile": 93.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 254.62, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 254.62, "10th_percentile": 254.62, "90th_percentile": 254.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 127.86, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 127.86, "10th_percentile": 127.86, "90th_percentile": 127.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 240.29, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 240.29, "10th_percentile": 240.29, "90th_percentile": 240.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 367.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 367.41, "10th_percentile": 367.41, "90th_percentile": 367.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 367.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 367.41, "10th_percentile": 367.41, "90th_percentile": 367.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 69.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 69.81, "10th_percentile": 69.81, "90th_percentile": 69.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 69.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 69.81, "10th_percentile": 69.81, "90th_percentile": 69.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 205.38, "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": 205.38, "10th_percentile": 205.38, "90th_percentile": 205.38, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 207.04, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.04, "10th_percentile": 207.04, "90th_percentile": 207.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 246.39, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 246.39, "10th_percentile": 246.39, "90th_percentile": 246.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 299.44, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 299.44, "10th_percentile": 299.44, "90th_percentile": 299.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 231.87, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 231.87, "10th_percentile": 231.87, "90th_percentile": 231.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 239.37, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 239.37, "10th_percentile": 239.37, "90th_percentile": 239.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "CARBIDOPA-LEVODOPA 50-200 MG ORAL TBER", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9409", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "51079-0923-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.95, "maximum": 15.5, "setting": "outpatient", "gross_charge": 15.5, "discounted_cash": 10.85, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 2.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2.95, "10th_percentile": 2.95, "90th_percentile": 2.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 12.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 12.4, "10th_percentile": 12.4, "90th_percentile": 12.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 7.49, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.49, "10th_percentile": 7.49, "90th_percentile": 7.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 7.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.02, "10th_percentile": 7.02, "90th_percentile": 7.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 11.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 11.63, "10th_percentile": 11.63, "90th_percentile": 11.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 6.98, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 6.98, "10th_percentile": 6.98, "90th_percentile": 6.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 10.1, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10.1, "10th_percentile": 10.1, "90th_percentile": 10.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 13.56, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 13.56, "10th_percentile": 13.56, "90th_percentile": 13.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 10.45, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 10.45, "10th_percentile": 10.45, "90th_percentile": 10.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 12.63, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.63, "10th_percentile": 12.63, "90th_percentile": 12.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 13.18, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 13.18, "10th_percentile": 13.18, "90th_percentile": 13.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 8.42, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 8.42, "10th_percentile": 8.42, "90th_percentile": 8.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 7.78, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.78, "10th_percentile": 7.78, "90th_percentile": 7.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 15.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 15.5, "10th_percentile": 15.5, "90th_percentile": 15.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 10.37, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.37, "10th_percentile": 10.37, "90th_percentile": 10.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 10.74, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.74, "10th_percentile": 10.74, "90th_percentile": 10.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.94, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 3.94, "10th_percentile": 3.94, "90th_percentile": 3.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 5.39, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 5.39, "10th_percentile": 5.39, "90th_percentile": 5.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 10.14, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.14, "10th_percentile": 10.14, "90th_percentile": 10.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 2.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2.95, "10th_percentile": 2.95, "90th_percentile": 2.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2.95, "10th_percentile": 2.95, "90th_percentile": 2.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 15.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 15.5, "10th_percentile": 15.5, "90th_percentile": 15.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 15.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 15.5, "10th_percentile": 15.5, "90th_percentile": 15.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8.73, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.73, "10th_percentile": 8.73, "90th_percentile": 8.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9.78, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.78, "10th_percentile": 9.78, "90th_percentile": 9.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 10.1, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10.1, "10th_percentile": 10.1, "90th_percentile": 10.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 12.63, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.63, "10th_percentile": 12.63, "90th_percentile": 12.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10.39, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.39, "10th_percentile": 10.39, "90th_percentile": 10.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8.66, "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": 8.66, "10th_percentile": 8.66, "90th_percentile": 8.66, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 15.5, "10th_percentile": 15.5, "90th_percentile": 15.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 15.5, "10th_percentile": 15.5, "90th_percentile": 15.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 15.5, "10th_percentile": 15.5, "90th_percentile": 15.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 15.5, "10th_percentile": 15.5, "90th_percentile": 15.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 15.5, "10th_percentile": 15.5, "90th_percentile": 15.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 15.5, "10th_percentile": 15.5, "90th_percentile": 15.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "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": 712.75, "maximum": 10329.75, "setting": "outpatient", "gross_charge": 10329.75, "discounted_cash": 7230.82, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10329.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10329.75, "10th_percentile": 10329.75, "90th_percentile": 10329.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10329.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10329.75, "10th_percentile": 10329.75, "90th_percentile": 10329.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 8439.41, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8439.41, "10th_percentile": 8439.41, "90th_percentile": 8439.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH THE ALLIANCE", "standard_charge_dollar": 5614.22, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 5614.22, "10th_percentile": 5614.22, "90th_percentile": 5614.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 6729.83, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 6729.83, "10th_percentile": 6729.83, "90th_percentile": 6729.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 9038.53, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 9038.53, "10th_percentile": 9038.53, "90th_percentile": 9038.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 4648.39, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 4648.39, "10th_percentile": 4648.39, "90th_percentile": 4648.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 8780.29, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 8780.29, "10th_percentile": 8780.29, "90th_percentile": 8780.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 8263.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 8263.8, "10th_percentile": 8263.8, "90th_percentile": 8263.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 10329.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 10329.75, "10th_percentile": 10329.75, "90th_percentile": 10329.75, "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": "VWH BCBS PPO", "standard_charge_dollar": 8439.41, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8439.41, "10th_percentile": 8439.41, "90th_percentile": 8439.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6507.74, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6507.74, "10th_percentile": 6507.74, "90th_percentile": 6507.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 6729.83, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 6729.83, "10th_percentile": 6729.83, "90th_percentile": 6729.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5774.33, "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": 5774.33, "10th_percentile": 5774.33, "90th_percentile": 5774.33, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6239.17, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6239.17, "10th_percentile": 6239.17, "90th_percentile": 6239.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6239.17, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6239.17, "10th_percentile": 6239.17, "90th_percentile": 6239.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1962.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1962.65, "10th_percentile": 1962.65, "90th_percentile": 1962.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1962.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1962.65, "10th_percentile": 1962.65, "90th_percentile": 1962.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1962.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1962.65, "10th_percentile": 1962.65, "90th_percentile": 1962.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 712.75, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 712.75, "10th_percentile": 712.75, "90th_percentile": 712.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 712.75, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 712.75, "10th_percentile": 712.75, "90th_percentile": 712.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 712.75, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 712.75, "10th_percentile": 712.75, "90th_percentile": 712.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 712.75, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 712.75, "10th_percentile": 712.75, "90th_percentile": 712.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 712.75, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 712.75, "10th_percentile": 712.75, "90th_percentile": 712.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 712.75, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 712.75, "10th_percentile": 712.75, "90th_percentile": 712.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_algorithm": "No contract line matched", "median_amount": 10329.75, "10th_percentile": 10329.75, "90th_percentile": 10329.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_algorithm": "No contract line matched", "median_amount": 10329.75, "10th_percentile": 10329.75, "90th_percentile": 10329.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_algorithm": "No contract line matched", "median_amount": 10329.75, "10th_percentile": 10329.75, "90th_percentile": 10329.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_algorithm": "No contract line matched", "median_amount": 10329.75, "10th_percentile": 10329.75, "90th_percentile": 10329.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "CATH 5FR DUAL POWERPIC SOLO", "code_information": [ { "code": "SUP-317522", "type": "CDM" }, { "code": "C1751", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 78.15, "maximum": 1132.55, "setting": "outpatient", "gross_charge": 1132.55, "discounted_cash": 792.78, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1132.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1132.55, "10th_percentile": 1132.55, "90th_percentile": 1132.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1132.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1132.55, "10th_percentile": 1132.55, "90th_percentile": 1132.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 990.98, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 990.98, "10th_percentile": 990.98, "90th_percentile": 990.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 547.02, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 547.02, "10th_percentile": 547.02, "90th_percentile": 547.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 513.05, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 513.05, "10th_percentile": 513.05, "90th_percentile": 513.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH THE ALLIANCE", "standard_charge_dollar": 615.54, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 615.54, "10th_percentile": 615.54, "90th_percentile": 615.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 509.65, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 509.65, "10th_percentile": 509.65, "90th_percentile": 509.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 906.04, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 906.04, "10th_percentile": 906.04, "90th_percentile": 906.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 763.34, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 763.34, "10th_percentile": 763.34, "90th_percentile": 763.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 962.67, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 962.67, "10th_percentile": 962.67, "90th_percentile": 962.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 925.29, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 925.29, "10th_percentile": 925.29, "90th_percentile": 925.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 849.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 849.41, "10th_percentile": 849.41, "90th_percentile": 849.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 737.86, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 737.86, "10th_percentile": 737.86, "90th_percentile": 737.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 568.54, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 568.54, "10th_percentile": 568.54, "90th_percentile": 568.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1132.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1132.55, "10th_percentile": 1132.55, "90th_percentile": 1132.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 757.68, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 757.68, "10th_percentile": 757.68, "90th_percentile": 757.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 784.86, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 784.86, "10th_percentile": 784.86, "90th_percentile": 784.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 394.13, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 394.13, "10th_percentile": 394.13, "90th_percentile": 394.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 287.67, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 287.67, "10th_percentile": 287.67, "90th_percentile": 287.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 740.69, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 740.69, "10th_percentile": 740.69, "90th_percentile": 740.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 713.51, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 713.51, "10th_percentile": 713.51, "90th_percentile": 713.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 925.29, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 925.29, "10th_percentile": 925.29, "90th_percentile": 925.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 737.86, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 737.86, "10th_percentile": 737.86, "90th_percentile": 737.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 633.1, "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": 633.1, "10th_percentile": 633.1, "90th_percentile": 633.1, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 684.06, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 684.06, "10th_percentile": 684.06, "90th_percentile": 684.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 684.06, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 684.06, "10th_percentile": 684.06, "90th_percentile": 684.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 215.18, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 215.18, "10th_percentile": 215.18, "90th_percentile": 215.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 215.18, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 215.18, "10th_percentile": 215.18, "90th_percentile": 215.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 215.18, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 215.18, "10th_percentile": 215.18, "90th_percentile": 215.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 78.15, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 78.15, "10th_percentile": 78.15, "90th_percentile": 78.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 78.15, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 78.15, "10th_percentile": 78.15, "90th_percentile": 78.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 78.15, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 78.15, "10th_percentile": 78.15, "90th_percentile": 78.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 78.15, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 78.15, "10th_percentile": 78.15, "90th_percentile": 78.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 78.15, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 78.15, "10th_percentile": 78.15, "90th_percentile": 78.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 78.15, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 78.15, "10th_percentile": 78.15, "90th_percentile": 78.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CATH COUDE CAR 22F 5CC NON 0168L22", "code_information": [ { "code": "SUP-2654", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 21.4, "maximum": 112.63, "setting": "outpatient", "gross_charge": 112.63, "discounted_cash": 78.84, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 112.63, "10th_percentile": 112.63, "90th_percentile": 112.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 112.63, "10th_percentile": 112.63, "90th_percentile": 112.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 112.63, "10th_percentile": 112.63, "90th_percentile": 112.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 112.63, "10th_percentile": 112.63, "90th_percentile": 112.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 112.63, "10th_percentile": 112.63, "90th_percentile": 112.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 112.63, "10th_percentile": 112.63, "90th_percentile": 112.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 21.4, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 21.4, "10th_percentile": 21.4, "90th_percentile": 21.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 98.55, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% 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; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 75.91, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 75.91, "10th_percentile": 75.91, "90th_percentile": 75.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 91.79, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.79, "10th_percentile": 91.79, "90th_percentile": 91.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 51.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.02, "10th_percentile": 51.02, "90th_percentile": 51.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 50.68, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 50.68, "10th_percentile": 50.68, "90th_percentile": 50.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 95.74, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 95.74, "10th_percentile": 95.74, "90th_percentile": 95.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 54.4, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 54.4, "10th_percentile": 54.4, "90th_percentile": 54.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 73.38, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 73.38, "10th_percentile": 73.38, "90th_percentile": 73.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 90.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 90.1, "10th_percentile": 90.1, "90th_percentile": 90.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 61.21, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 61.21, "10th_percentile": 61.21, "90th_percentile": 61.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 84.47, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 84.47, "10th_percentile": 84.47, "90th_percentile": 84.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 112.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 112.63, "10th_percentile": 112.63, "90th_percentile": 112.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 75.35, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 75.35, "10th_percentile": 75.35, "90th_percentile": 75.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 56.54, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.54, "10th_percentile": 56.54, "90th_percentile": 56.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 28.61, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 28.61, "10th_percentile": 28.61, "90th_percentile": 28.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 78.05, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.05, "10th_percentile": 78.05, "90th_percentile": 78.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 39.2, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 39.2, "10th_percentile": 39.2, "90th_percentile": 39.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 73.66, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.66, "10th_percentile": 73.66, "90th_percentile": 73.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 112.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 112.63, "10th_percentile": 112.63, "90th_percentile": 112.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 112.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 112.63, "10th_percentile": 112.63, "90th_percentile": 112.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 21.4, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 21.4, "10th_percentile": 21.4, "90th_percentile": 21.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 21.4, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 21.4, "10th_percentile": 21.4, "90th_percentile": 21.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 62.96, "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": 62.96, "10th_percentile": 62.96, "90th_percentile": 62.96, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 63.47, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.47, "10th_percentile": 63.47, "90th_percentile": 63.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 75.53, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 75.53, "10th_percentile": 75.53, "90th_percentile": 75.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 91.79, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.79, "10th_percentile": 91.79, "90th_percentile": 91.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 71.08, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.08, "10th_percentile": 71.08, "90th_percentile": 71.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 73.38, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 73.38, "10th_percentile": 73.38, "90th_percentile": 73.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "CATH URIN FOL 12FX10ML 2WY SIL DYND11500", "code_information": [ { "code": "SUP-318983", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 7.79, "maximum": 41.0, "setting": "outpatient", "gross_charge": 41.0, "discounted_cash": 28.7, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 7.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 7.79, "10th_percentile": 7.79, "90th_percentile": 7.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 35.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 35.88, "10th_percentile": 35.88, "90th_percentile": 35.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 27.63, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 27.63, "10th_percentile": 27.63, "90th_percentile": 27.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 33.42, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.42, "10th_percentile": 33.42, "90th_percentile": 33.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 18.57, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.57, "10th_percentile": 18.57, "90th_percentile": 18.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 18.45, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 18.45, "10th_percentile": 18.45, "90th_percentile": 18.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 34.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 34.85, "10th_percentile": 34.85, "90th_percentile": 34.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 19.8, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.8, "10th_percentile": 19.8, "90th_percentile": 19.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 26.71, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 26.71, "10th_percentile": 26.71, "90th_percentile": 26.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 32.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 32.8, "10th_percentile": 32.8, "90th_percentile": 32.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 22.28, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 22.28, "10th_percentile": 22.28, "90th_percentile": 22.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 30.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 30.75, "10th_percentile": 30.75, "90th_percentile": 30.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 41.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 27.43, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.43, "10th_percentile": 27.43, "90th_percentile": 27.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 20.58, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.58, "10th_percentile": 20.58, "90th_percentile": 20.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 10.41, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 10.41, "10th_percentile": 10.41, "90th_percentile": 10.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 28.41, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.41, "10th_percentile": 28.41, "90th_percentile": 28.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 14.27, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 14.27, "10th_percentile": 14.27, "90th_percentile": 14.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 26.81, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.81, "10th_percentile": 26.81, "90th_percentile": 26.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 41.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 41.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 7.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 7.79, "10th_percentile": 7.79, "90th_percentile": 7.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 7.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 7.79, "10th_percentile": 7.79, "90th_percentile": 7.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 22.92, "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": 22.92, "10th_percentile": 22.92, "90th_percentile": 22.92, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 23.1, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.1, "10th_percentile": 23.1, "90th_percentile": 23.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 27.49, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.49, "10th_percentile": 27.49, "90th_percentile": 27.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 33.42, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.42, "10th_percentile": 33.42, "90th_percentile": 33.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 25.88, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.88, "10th_percentile": 25.88, "90th_percentile": 25.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 26.71, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 26.71, "10th_percentile": 26.71, "90th_percentile": 26.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "CATHETER 5FR OPEN END M0064002011 (M0064002010)", "code_information": [ { "code": "SUP-320075", "type": "CDM" }, { "code": "C1758", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 8.48, "maximum": 122.89, "setting": "outpatient", "gross_charge": 122.89, "discounted_cash": 86.02, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 122.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 122.89, "10th_percentile": 122.89, "90th_percentile": 122.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 122.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 122.89, "10th_percentile": 122.89, "90th_percentile": 122.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 107.53, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 107.53, "10th_percentile": 107.53, "90th_percentile": 107.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 59.36, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.36, "10th_percentile": 59.36, "90th_percentile": 59.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 55.67, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.67, "10th_percentile": 55.67, "90th_percentile": 55.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH THE ALLIANCE", "standard_charge_dollar": 66.79, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 66.79, "10th_percentile": 66.79, "90th_percentile": 66.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 55.3, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 55.3, "10th_percentile": 55.3, "90th_percentile": 55.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 98.31, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 98.31, "10th_percentile": 98.31, "90th_percentile": 98.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 82.83, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 82.83, "10th_percentile": 82.83, "90th_percentile": 82.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 104.46, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 104.46, "10th_percentile": 104.46, "90th_percentile": 104.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 100.4, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.4, "10th_percentile": 100.4, "90th_percentile": 100.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 92.17, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 92.17, "10th_percentile": 92.17, "90th_percentile": 92.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 80.06, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 80.06, "10th_percentile": 80.06, "90th_percentile": 80.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 61.69, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.69, "10th_percentile": 61.69, "90th_percentile": 61.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 122.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 122.89, "10th_percentile": 122.89, "90th_percentile": 122.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 82.21, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.21, "10th_percentile": 82.21, "90th_percentile": 82.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 85.16, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.16, "10th_percentile": 85.16, "90th_percentile": 85.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 42.77, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 42.77, "10th_percentile": 42.77, "90th_percentile": 42.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 31.21, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 31.21, "10th_percentile": 31.21, "90th_percentile": 31.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 80.37, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.37, "10th_percentile": 80.37, "90th_percentile": 80.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 77.42, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.42, "10th_percentile": 77.42, "90th_percentile": 77.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 100.4, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.4, "10th_percentile": 100.4, "90th_percentile": 100.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 80.06, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 80.06, "10th_percentile": 80.06, "90th_percentile": 80.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 68.7, "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": 68.7, "10th_percentile": 68.7, "90th_percentile": 68.7, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 74.23, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.23, "10th_percentile": 74.23, "90th_percentile": 74.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 74.23, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.23, "10th_percentile": 74.23, "90th_percentile": 74.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 23.35, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 23.35, "10th_percentile": 23.35, "90th_percentile": 23.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 23.35, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 23.35, "10th_percentile": 23.35, "90th_percentile": 23.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 23.35, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 23.35, "10th_percentile": 23.35, "90th_percentile": 23.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 8.48, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 8.48, "10th_percentile": 8.48, "90th_percentile": 8.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 8.48, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 8.48, "10th_percentile": 8.48, "90th_percentile": 8.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 8.48, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 8.48, "10th_percentile": 8.48, "90th_percentile": 8.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 8.48, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 8.48, "10th_percentile": 8.48, "90th_percentile": 8.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 8.48, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 8.48, "10th_percentile": 8.48, "90th_percentile": 8.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 8.48, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 8.48, "10th_percentile": 8.48, "90th_percentile": 8.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CATHETER AXXCESS 5FR", "code_information": [ { "code": "SUP-320105", "type": "CDM" }, { "code": "C1758", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 17.84, "maximum": 258.55, "setting": "outpatient", "gross_charge": 258.55, "discounted_cash": 180.98, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 258.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 258.55, "10th_percentile": 258.55, "90th_percentile": 258.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 258.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 258.55, "10th_percentile": 258.55, "90th_percentile": 258.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 226.23, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 226.23, "10th_percentile": 226.23, "90th_percentile": 226.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 124.88, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.88, "10th_percentile": 124.88, "90th_percentile": 124.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 117.12, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 117.12, "10th_percentile": 117.12, "90th_percentile": 117.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH THE ALLIANCE", "standard_charge_dollar": 140.52, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 140.52, "10th_percentile": 140.52, "90th_percentile": 140.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 116.35, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 116.35, "10th_percentile": 116.35, "90th_percentile": 116.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 206.84, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 206.84, "10th_percentile": 206.84, "90th_percentile": 206.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 174.26, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 174.26, "10th_percentile": 174.26, "90th_percentile": 174.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 219.77, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 219.77, "10th_percentile": 219.77, "90th_percentile": 219.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 211.24, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 211.24, "10th_percentile": 211.24, "90th_percentile": 211.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 193.91, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 193.91, "10th_percentile": 193.91, "90th_percentile": 193.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 168.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 168.45, "10th_percentile": 168.45, "90th_percentile": 168.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 129.79, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.79, "10th_percentile": 129.79, "90th_percentile": 129.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 258.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 258.55, "10th_percentile": 258.55, "90th_percentile": 258.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 172.97, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 172.97, "10th_percentile": 172.97, "90th_percentile": 172.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 179.18, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.18, "10th_percentile": 179.18, "90th_percentile": 179.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 89.98, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 89.98, "10th_percentile": 89.98, "90th_percentile": 89.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 65.67, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 65.67, "10th_percentile": 65.67, "90th_percentile": 65.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 169.09, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.09, "10th_percentile": 169.09, "90th_percentile": 169.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 162.89, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.89, "10th_percentile": 162.89, "90th_percentile": 162.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 211.24, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 211.24, "10th_percentile": 211.24, "90th_percentile": 211.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 168.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 168.45, "10th_percentile": 168.45, "90th_percentile": 168.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 144.53, "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": 144.53, "10th_percentile": 144.53, "90th_percentile": 144.53, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 156.16, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.16, "10th_percentile": 156.16, "90th_percentile": 156.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 156.16, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.16, "10th_percentile": 156.16, "90th_percentile": 156.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 49.12, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 49.12, "10th_percentile": 49.12, "90th_percentile": 49.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 49.12, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 49.12, "10th_percentile": 49.12, "90th_percentile": 49.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 49.12, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 49.12, "10th_percentile": 49.12, "90th_percentile": 49.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 17.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 17.84, "10th_percentile": 17.84, "90th_percentile": 17.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 17.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 17.84, "10th_percentile": 17.84, "90th_percentile": 17.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 17.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 17.84, "10th_percentile": 17.84, "90th_percentile": 17.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 17.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 17.84, "10th_percentile": 17.84, "90th_percentile": 17.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 17.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 17.84, "10th_percentile": 17.84, "90th_percentile": 17.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 17.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 17.84, "10th_percentile": 17.84, "90th_percentile": 17.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CATHETER FOLEY 16FR 5CC 3WAY S", "code_information": [ { "code": "SUP-162898", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 46.96, "maximum": 247.17, "setting": "outpatient", "gross_charge": 247.17, "discounted_cash": 173.02, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 247.17, "10th_percentile": 247.17, "90th_percentile": 247.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 247.17, "10th_percentile": 247.17, "90th_percentile": 247.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 247.17, "10th_percentile": 247.17, "90th_percentile": 247.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 247.17, "10th_percentile": 247.17, "90th_percentile": 247.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 247.17, "10th_percentile": 247.17, "90th_percentile": 247.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 247.17, "10th_percentile": 247.17, "90th_percentile": 247.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 46.96, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 46.96, "10th_percentile": 46.96, "90th_percentile": 46.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 216.27, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 216.27, "10th_percentile": 216.27, "90th_percentile": 216.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 166.59, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 166.59, "10th_percentile": 166.59, "90th_percentile": 166.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 201.44, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 201.44, "10th_percentile": 201.44, "90th_percentile": 201.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 111.97, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.97, "10th_percentile": 111.97, "90th_percentile": 111.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 111.23, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 111.23, "10th_percentile": 111.23, "90th_percentile": 111.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 210.09, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 210.09, "10th_percentile": 210.09, "90th_percentile": 210.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 119.38, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 119.38, "10th_percentile": 119.38, "90th_percentile": 119.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 161.03, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 161.03, "10th_percentile": 161.03, "90th_percentile": 161.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 197.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 197.74, "10th_percentile": 197.74, "90th_percentile": 197.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 134.34, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 134.34, "10th_percentile": 134.34, "90th_percentile": 134.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 185.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 185.38, "10th_percentile": 185.38, "90th_percentile": 185.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 247.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 247.17, "10th_percentile": 247.17, "90th_percentile": 247.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 165.36, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.36, "10th_percentile": 165.36, "90th_percentile": 165.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 124.08, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.08, "10th_percentile": 124.08, "90th_percentile": 124.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 62.78, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 62.78, "10th_percentile": 62.78, "90th_percentile": 62.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 171.29, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 171.29, "10th_percentile": 171.29, "90th_percentile": 171.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 86.02, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 86.02, "10th_percentile": 86.02, "90th_percentile": 86.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 161.65, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 161.65, "10th_percentile": 161.65, "90th_percentile": 161.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 247.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 247.17, "10th_percentile": 247.17, "90th_percentile": 247.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 247.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 247.17, "10th_percentile": 247.17, "90th_percentile": 247.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 46.96, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 46.96, "10th_percentile": 46.96, "90th_percentile": 46.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 46.96, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 46.96, "10th_percentile": 46.96, "90th_percentile": 46.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 138.17, "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": 138.17, "10th_percentile": 138.17, "90th_percentile": 138.17, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 139.28, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.28, "10th_percentile": 139.28, "90th_percentile": 139.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 165.75, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.75, "10th_percentile": 165.75, "90th_percentile": 165.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 201.44, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 201.44, "10th_percentile": 201.44, "90th_percentile": 201.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 155.99, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 155.99, "10th_percentile": 155.99, "90th_percentile": 155.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 161.03, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 161.03, "10th_percentile": 161.03, "90th_percentile": 161.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "CATHETER POWER PORT CLEARVUE SLIM 8FR 1618000", "code_information": [ { "code": "SUP-332913", "type": "CDM" }, { "code": "C1788", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 211.24, "maximum": 3061.52, "setting": "outpatient", "gross_charge": 3061.52, "discounted_cash": 2143.06, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3061.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3061.52, "10th_percentile": 3061.52, "90th_percentile": 3061.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3061.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3061.52, "10th_percentile": 3061.52, "90th_percentile": 3061.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2678.83, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2678.83, "10th_percentile": 2678.83, "90th_percentile": 2678.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1478.71, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1478.71, "10th_percentile": 1478.71, "90th_percentile": 1478.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1386.87, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1386.87, "10th_percentile": 1386.87, "90th_percentile": 1386.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH THE ALLIANCE", "standard_charge_dollar": 1663.94, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1663.94, "10th_percentile": 1663.94, "90th_percentile": 1663.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1377.68, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1377.68, "10th_percentile": 1377.68, "90th_percentile": 1377.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2449.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2449.22, "10th_percentile": 2449.22, "90th_percentile": 2449.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2063.46, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2063.46, "10th_percentile": 2063.46, "90th_percentile": 2063.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2602.29, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2602.29, "10th_percentile": 2602.29, "90th_percentile": 2602.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2501.26, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2501.26, "10th_percentile": 2501.26, "90th_percentile": 2501.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2296.14, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2296.14, "10th_percentile": 2296.14, "90th_percentile": 2296.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1994.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1994.58, "10th_percentile": 1994.58, "90th_percentile": 1994.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1536.88, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1536.88, "10th_percentile": 1536.88, "90th_percentile": 1536.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3061.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3061.52, "10th_percentile": 3061.52, "90th_percentile": 3061.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2048.16, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2048.16, "10th_percentile": 2048.16, "90th_percentile": 2048.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2121.63, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2121.63, "10th_percentile": 2121.63, "90th_percentile": 2121.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1065.41, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1065.41, "10th_percentile": 1065.41, "90th_percentile": 1065.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 777.63, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 777.63, "10th_percentile": 777.63, "90th_percentile": 777.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2002.23, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2002.23, "10th_percentile": 2002.23, "90th_percentile": 2002.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1928.76, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1928.76, "10th_percentile": 1928.76, "90th_percentile": 1928.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2501.26, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2501.26, "10th_percentile": 2501.26, "90th_percentile": 2501.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1994.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1994.58, "10th_percentile": 1994.58, "90th_percentile": 1994.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1711.39, "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": 1711.39, "10th_percentile": 1711.39, "90th_percentile": 1711.39, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1849.16, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1849.16, "10th_percentile": 1849.16, "90th_percentile": 1849.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1849.16, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1849.16, "10th_percentile": 1849.16, "90th_percentile": 1849.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 581.69, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 581.69, "10th_percentile": 581.69, "90th_percentile": 581.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 581.69, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 581.69, "10th_percentile": 581.69, "90th_percentile": 581.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 581.69, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 581.69, "10th_percentile": 581.69, "90th_percentile": 581.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 211.24, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 211.24, "10th_percentile": 211.24, "90th_percentile": 211.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 211.24, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 211.24, "10th_percentile": 211.24, "90th_percentile": 211.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 211.24, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 211.24, "10th_percentile": 211.24, "90th_percentile": 211.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 211.24, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 211.24, "10th_percentile": 211.24, "90th_percentile": 211.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 211.24, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 211.24, "10th_percentile": 211.24, "90th_percentile": 211.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 211.24, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 211.24, "10th_percentile": 211.24, "90th_percentile": 211.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CATHETER THORACIC STRAIGHT 32FR (ARGYLE) 8888570556", "code_information": [ { "code": "SUP-2675", "type": "CDM" }, { "code": "C1729", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 4.5, "maximum": 65.2, "setting": "outpatient", "gross_charge": 65.2, "discounted_cash": 45.64, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 42.48, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 42.48, "10th_percentile": 42.48, "90th_percentile": 42.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 52.16, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 52.16, "10th_percentile": 52.16, "90th_percentile": 52.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 43.94, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 43.94, "10th_percentile": 43.94, "90th_percentile": 43.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 29.34, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 29.34, "10th_percentile": 29.34, "90th_percentile": 29.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 53.27, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.27, "10th_percentile": 53.27, "90th_percentile": 53.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 55.42, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 55.42, "10th_percentile": 55.42, "90th_percentile": 55.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 57.05, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 57.05, "10th_percentile": 57.05, "90th_percentile": 57.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 35.44, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 35.44, "10th_percentile": 35.44, "90th_percentile": 35.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 31.49, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.49, "10th_percentile": 31.49, "90th_percentile": 31.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 29.54, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.54, "10th_percentile": 29.54, "90th_percentile": 29.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 48.9, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 48.9, "10th_percentile": 48.9, "90th_percentile": 48.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 65.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 65.2, "10th_percentile": 65.2, "90th_percentile": 65.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 43.62, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.62, "10th_percentile": 43.62, "90th_percentile": 43.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 32.73, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.73, "10th_percentile": 32.73, "90th_percentile": 32.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 16.56, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 16.56, "10th_percentile": 16.56, "90th_percentile": 16.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 22.69, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 22.69, "10th_percentile": 22.69, "90th_percentile": 22.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 45.18, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.18, "10th_percentile": 45.18, "90th_percentile": 45.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 42.64, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.64, "10th_percentile": 42.64, "90th_percentile": 42.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.2, "10th_percentile": 65.2, "90th_percentile": 65.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.2, "10th_percentile": 65.2, "90th_percentile": 65.2, "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": "VWH BCBS HMO", "standard_charge_dollar": 42.48, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 42.48, "10th_percentile": 42.48, "90th_percentile": 42.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 53.27, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.27, "10th_percentile": 53.27, "90th_percentile": 53.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 41.08, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.08, "10th_percentile": 41.08, "90th_percentile": 41.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 36.45, "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": 36.45, "10th_percentile": 36.45, "90th_percentile": 36.45, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 39.38, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.38, "10th_percentile": 39.38, "90th_percentile": 39.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 39.38, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.38, "10th_percentile": 39.38, "90th_percentile": 39.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 12.39, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 12.39, "10th_percentile": 12.39, "90th_percentile": 12.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 12.39, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 12.39, "10th_percentile": 12.39, "90th_percentile": 12.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 12.39, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 12.39, "10th_percentile": 12.39, "90th_percentile": 12.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.5, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.5, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.5, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.5, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.5, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 4.5, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% 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": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CAUTERY AQUAMANTYS SEALER 6.0 (23-112-1)", "code_information": [ { "code": "SUP-111872", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 522.76, "maximum": 2751.39, "setting": "outpatient", "gross_charge": 2751.39, "discounted_cash": 1925.97, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2751.39, "10th_percentile": 2751.39, "90th_percentile": 2751.39, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2751.39, "10th_percentile": 2751.39, "90th_percentile": 2751.39, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2751.39, "10th_percentile": 2751.39, "90th_percentile": 2751.39, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2751.39, "10th_percentile": 2751.39, "90th_percentile": 2751.39, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2751.39, "10th_percentile": 2751.39, "90th_percentile": 2751.39, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2751.39, "10th_percentile": 2751.39, "90th_percentile": 2751.39, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 522.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 522.76, "10th_percentile": 522.76, "90th_percentile": 522.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2407.47, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2407.47, "10th_percentile": 2407.47, "90th_percentile": 2407.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1854.44, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1854.44, "10th_percentile": 1854.44, "90th_percentile": 1854.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2242.38, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2242.38, "10th_percentile": 2242.38, "90th_percentile": 2242.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1246.38, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1246.38, "10th_percentile": 1246.38, "90th_percentile": 1246.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1238.13, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1238.13, "10th_percentile": 1238.13, "90th_percentile": 1238.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2338.68, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2338.68, "10th_percentile": 2338.68, "90th_percentile": 2338.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1328.92, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1328.92, "10th_percentile": 1328.92, "90th_percentile": 1328.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1792.53, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1792.53, "10th_percentile": 1792.53, "90th_percentile": 1792.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2201.11, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2201.11, "10th_percentile": 2201.11, "90th_percentile": 2201.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1495.38, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1495.38, "10th_percentile": 1495.38, "90th_percentile": 1495.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2063.54, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2063.54, "10th_percentile": 2063.54, "90th_percentile": 2063.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2751.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2751.39, "10th_percentile": 2751.39, "90th_percentile": 2751.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1840.68, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1840.68, "10th_percentile": 1840.68, "90th_percentile": 1840.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1381.2, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1381.2, "10th_percentile": 1381.2, "90th_percentile": 1381.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 698.85, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 698.85, "10th_percentile": 698.85, "90th_percentile": 698.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1906.71, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1906.71, "10th_percentile": 1906.71, "90th_percentile": 1906.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 957.48, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 957.48, "10th_percentile": 957.48, "90th_percentile": 957.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1799.41, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1799.41, "10th_percentile": 1799.41, "90th_percentile": 1799.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2751.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2751.39, "10th_percentile": 2751.39, "90th_percentile": 2751.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2751.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2751.39, "10th_percentile": 2751.39, "90th_percentile": 2751.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 522.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 522.76, "10th_percentile": 522.76, "90th_percentile": 522.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 522.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 522.76, "10th_percentile": 522.76, "90th_percentile": 522.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1538.03, "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": 1538.03, "10th_percentile": 1538.03, "90th_percentile": 1538.03, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1550.41, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1550.41, "10th_percentile": 1550.41, "90th_percentile": 1550.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1845.08, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1845.08, "10th_percentile": 1845.08, "90th_percentile": 1845.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2242.38, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2242.38, "10th_percentile": 2242.38, "90th_percentile": 2242.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1736.4, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1736.4, "10th_percentile": 1736.4, "90th_percentile": 1736.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1792.53, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1792.53, "10th_percentile": 1792.53, "90th_percentile": 1792.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "CEFUROXIME AXETIL 250 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9495", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0272-94", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.74, "maximum": 140.75, "setting": "outpatient", "gross_charge": 140.75, "discounted_cash": 98.52, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 112.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 112.6, "10th_percentile": 112.6, "90th_percentile": 112.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 67.98, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.98, "10th_percentile": 67.98, "90th_percentile": 67.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 63.76, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.76, "10th_percentile": 63.76, "90th_percentile": 63.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 105.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 105.56, "10th_percentile": 105.56, "90th_percentile": 105.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 63.34, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 63.34, "10th_percentile": 63.34, "90th_percentile": 63.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 91.7, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 91.7, "10th_percentile": 91.7, "90th_percentile": 91.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 123.16, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 123.16, "10th_percentile": 123.16, "90th_percentile": 123.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 94.87, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 94.87, "10th_percentile": 94.87, "90th_percentile": 94.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 114.71, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 114.71, "10th_percentile": 114.71, "90th_percentile": 114.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 119.64, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 119.64, "10th_percentile": 119.64, "90th_percentile": 119.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 76.5, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 76.5, "10th_percentile": 76.5, "90th_percentile": 76.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 70.66, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.66, "10th_percentile": 70.66, "90th_percentile": 70.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 140.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 140.75, "10th_percentile": 140.75, "90th_percentile": 140.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 94.16, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.16, "10th_percentile": 94.16, "90th_percentile": 94.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 97.54, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.54, "10th_percentile": 97.54, "90th_percentile": 97.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 35.75, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 35.75, "10th_percentile": 35.75, "90th_percentile": 35.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 48.98, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 48.98, "10th_percentile": 48.98, "90th_percentile": 48.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 92.05, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.05, "10th_percentile": 92.05, "90th_percentile": 92.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 26.74, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 26.74, "10th_percentile": 26.74, "90th_percentile": 26.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 26.74, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 26.74, "10th_percentile": 26.74, "90th_percentile": 26.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 140.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 140.75, "10th_percentile": 140.75, "90th_percentile": 140.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 140.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 140.75, "10th_percentile": 140.75, "90th_percentile": 140.75, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 79.31, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.31, "10th_percentile": 79.31, "90th_percentile": 79.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 88.83, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.83, "10th_percentile": 88.83, "90th_percentile": 88.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 91.7, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 91.7, "10th_percentile": 91.7, "90th_percentile": 91.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 114.71, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 114.71, "10th_percentile": 114.71, "90th_percentile": 114.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 94.39, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.39, "10th_percentile": 94.39, "90th_percentile": 94.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 78.68, "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": 78.68, "10th_percentile": 78.68, "90th_percentile": 78.68, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 140.75, "10th_percentile": 140.75, "90th_percentile": 140.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 140.75, "10th_percentile": 140.75, "90th_percentile": 140.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 140.75, "10th_percentile": 140.75, "90th_percentile": 140.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 140.75, "10th_percentile": 140.75, "90th_percentile": 140.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 140.75, "10th_percentile": 140.75, "90th_percentile": 140.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 140.75, "10th_percentile": 140.75, "90th_percentile": 140.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 26.74, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 26.74, "10th_percentile": 26.74, "90th_percentile": 26.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "CEPHALEXIN 250 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9499", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0152-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.33, "maximum": 12.25, "setting": "outpatient", "gross_charge": 12.25, "discounted_cash": 8.57, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 2.33, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2.33, "10th_percentile": 2.33, "90th_percentile": 2.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 9.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 5.92, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.92, "10th_percentile": 5.92, "90th_percentile": 5.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 5.55, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.55, "10th_percentile": 5.55, "90th_percentile": 5.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 9.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 9.19, "10th_percentile": 9.19, "90th_percentile": 9.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 5.51, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 7.98, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 7.98, "10th_percentile": 7.98, "90th_percentile": 7.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 10.72, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 10.72, "10th_percentile": 10.72, "90th_percentile": 10.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 8.26, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 8.26, "10th_percentile": 8.26, "90th_percentile": 8.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 9.98, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.98, "10th_percentile": 9.98, "90th_percentile": 9.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 10.41, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 10.41, "10th_percentile": 10.41, "90th_percentile": 10.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 6.66, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 6.66, "10th_percentile": 6.66, "90th_percentile": 6.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 6.15, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.15, "10th_percentile": 6.15, "90th_percentile": 6.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 8.2, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.2, "10th_percentile": 8.2, "90th_percentile": 8.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 8.49, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.49, "10th_percentile": 8.49, "90th_percentile": 8.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.11, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% 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 Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 4.26, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 4.26, "10th_percentile": 4.26, "90th_percentile": 4.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 8.01, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.01, "10th_percentile": 8.01, "90th_percentile": 8.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 2.33, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2.33, "10th_percentile": 2.33, "90th_percentile": 2.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2.33, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2.33, "10th_percentile": 2.33, "90th_percentile": 2.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.9, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.9, "10th_percentile": 6.9, "90th_percentile": 6.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.73, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.73, "10th_percentile": 7.73, "90th_percentile": 7.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 7.98, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 7.98, "10th_percentile": 7.98, "90th_percentile": 7.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 9.98, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.98, "10th_percentile": 9.98, "90th_percentile": 9.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.21, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.21, "10th_percentile": 8.21, "90th_percentile": 8.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.85, "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": 6.85, "10th_percentile": 6.85, "90th_percentile": 6.85, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "CHG/SQCM GRAFT JCKT 4X8CM=32 SQ CM MTRX TSS REGEN", "code_information": [ { "code": "SUP-419193", "type": "CDM" }, { "code": "Q4107", "type": "HCPCS" }, { "code": "0636", "type": "RC" } ], "standard_charges": [ { "minimum": 53.97, "maximum": 782.12, "setting": "outpatient", "gross_charge": 782.12, "discounted_cash": 547.48, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 684.36, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 684.36, "10th_percentile": 684.36, "90th_percentile": 684.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 351.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 351.95, "10th_percentile": 351.95, "90th_percentile": 351.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 664.8, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 664.8, "10th_percentile": 664.8, "90th_percentile": 664.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 425.08, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 425.08, "10th_percentile": 425.08, "90th_percentile": 425.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 586.59, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 586.59, "10th_percentile": 586.59, "90th_percentile": 586.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 527.15, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 527.15, "10th_percentile": 527.15, "90th_percentile": 527.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 509.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 509.55, "10th_percentile": 509.55, "90th_percentile": 509.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 782.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 782.12, "10th_percentile": 782.12, "90th_percentile": 782.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 625.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 625.7, "10th_percentile": 625.7, "90th_percentile": 625.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 638.99, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 638.99, "10th_percentile": 638.99, "90th_percentile": 638.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 511.51, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 511.51, "10th_percentile": 511.51, "90th_percentile": 511.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 542.01, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 542.01, "10th_percentile": 542.01, "90th_percentile": 542.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 198.66, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 198.66, "10th_percentile": 198.66, "90th_percentile": 198.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 272.18, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 272.18, "10th_percentile": 272.18, "90th_percentile": 272.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 782.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 782.12, "10th_percentile": 782.12, "90th_percentile": 782.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 782.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 782.12, "10th_percentile": 782.12, "90th_percentile": 782.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 148.6, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 148.6, "10th_percentile": 148.6, "90th_percentile": 148.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 148.6, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 148.6, "10th_percentile": 148.6, "90th_percentile": 148.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 148.6, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 148.6, "10th_percentile": 148.6, "90th_percentile": 148.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 638.99, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 638.99, "10th_percentile": 638.99, "90th_percentile": 638.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 492.74, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 492.74, "10th_percentile": 492.74, "90th_percentile": 492.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 437.21, "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": 437.21, "10th_percentile": 437.21, "90th_percentile": 437.21, "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": "VWH BCBS HMO", "standard_charge_dollar": 509.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 509.55, "10th_percentile": 509.55, "90th_percentile": 509.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 472.4, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 472.4, "10th_percentile": 472.4, "90th_percentile": 472.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 472.4, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 472.4, "10th_percentile": 472.4, "90th_percentile": 472.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual 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": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 53.97, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 53.97, "10th_percentile": 53.97, "90th_percentile": 53.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 53.97, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 53.97, "10th_percentile": 53.97, "90th_percentile": 53.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 53.97, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 53.97, "10th_percentile": 53.97, "90th_percentile": 53.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 53.97, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 53.97, "10th_percentile": 53.97, "90th_percentile": 53.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 53.97, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 53.97, "10th_percentile": 53.97, "90th_percentile": 53.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 53.97, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 53.97, "10th_percentile": 53.97, "90th_percentile": 53.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CHG/SQCM MESH PERMACOL 15X20CM X 1.5MM=300 SQ CM", "code_information": [ { "code": "SUP-317346", "type": "CDM" }, { "code": "C9364", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 15.94, "maximum": 231.0, "setting": "outpatient", "gross_charge": 231.0, "discounted_cash": 161.7, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 231.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 231.0, "10th_percentile": 231.0, "90th_percentile": 231.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 231.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 231.0, "10th_percentile": 231.0, "90th_percentile": 231.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 202.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 202.13, "10th_percentile": 202.13, "90th_percentile": 202.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 188.27, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.27, "10th_percentile": 188.27, "90th_percentile": 188.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 43.89, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 43.89, "10th_percentile": 43.89, "90th_percentile": 43.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 43.89, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 43.89, "10th_percentile": 43.89, "90th_percentile": 43.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 125.55, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 125.55, "10th_percentile": 125.55, "90th_percentile": 125.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 103.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 103.95, "10th_percentile": 103.95, "90th_percentile": 103.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 184.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 184.8, "10th_percentile": 184.8, "90th_percentile": 184.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 155.69, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 155.69, "10th_percentile": 155.69, "90th_percentile": 155.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 196.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 196.35, "10th_percentile": 196.35, "90th_percentile": 196.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 173.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 173.25, "10th_percentile": 173.25, "90th_percentile": 173.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 150.5, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 150.5, "10th_percentile": 150.5, "90th_percentile": 150.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 115.96, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 115.96, "10th_percentile": 115.96, "90th_percentile": 115.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 231.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 231.0, "10th_percentile": 231.0, "90th_percentile": 231.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 154.54, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 154.54, "10th_percentile": 154.54, "90th_percentile": 154.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 160.08, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.08, "10th_percentile": 160.08, "90th_percentile": 160.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 80.39, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 80.39, "10th_percentile": 80.39, "90th_percentile": 80.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 58.67, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 58.67, "10th_percentile": 58.67, "90th_percentile": 58.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 151.07, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 151.07, "10th_percentile": 151.07, "90th_percentile": 151.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 154.91, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 154.91, "10th_percentile": 154.91, "90th_percentile": 154.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 145.78, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.78, "10th_percentile": 145.78, "90th_percentile": 145.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 130.17, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.17, "10th_percentile": 130.17, "90th_percentile": 130.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 188.27, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.27, "10th_percentile": 188.27, "90th_percentile": 188.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 150.5, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 150.5, "10th_percentile": 150.5, "90th_percentile": 150.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 129.13, "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": 129.13, "10th_percentile": 129.13, "90th_percentile": 129.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 43.89, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 43.89, "10th_percentile": 43.89, "90th_percentile": 43.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.94, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.94, "10th_percentile": 15.94, "90th_percentile": 15.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.94, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.94, "10th_percentile": 15.94, "90th_percentile": 15.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.94, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.94, "10th_percentile": 15.94, "90th_percentile": 15.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.94, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.94, "10th_percentile": 15.94, "90th_percentile": 15.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.94, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.94, "10th_percentile": 15.94, "90th_percentile": 15.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.94, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.94, "10th_percentile": 15.94, "90th_percentile": 15.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CHLORTHALIDONE 25 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-1661", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0317-95", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.54, "maximum": 60.75, "setting": "outpatient", "gross_charge": 60.75, "discounted_cash": 42.52, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 11.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 11.54, "10th_percentile": 11.54, "90th_percentile": 11.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 48.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 48.6, "10th_percentile": 48.6, "90th_percentile": 48.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 29.34, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.34, "10th_percentile": 29.34, "90th_percentile": 29.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 27.52, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.52, "10th_percentile": 27.52, "90th_percentile": 27.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 45.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 45.56, "10th_percentile": 45.56, "90th_percentile": 45.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 27.34, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 27.34, "10th_percentile": 27.34, "90th_percentile": 27.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 39.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 39.58, "10th_percentile": 39.58, "90th_percentile": 39.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 53.16, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 53.16, "10th_percentile": 53.16, "90th_percentile": 53.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 40.95, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 40.95, "10th_percentile": 40.95, "90th_percentile": 40.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 49.51, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.51, "10th_percentile": 49.51, "90th_percentile": 49.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 51.64, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 51.64, "10th_percentile": 51.64, "90th_percentile": 51.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 33.02, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 33.02, "10th_percentile": 33.02, "90th_percentile": 33.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 30.5, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.5, "10th_percentile": 30.5, "90th_percentile": 30.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 60.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% 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 OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 40.64, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.64, "10th_percentile": 40.64, "90th_percentile": 40.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 42.1, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.1, "10th_percentile": 42.1, "90th_percentile": 42.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 15.43, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 15.43, "10th_percentile": 15.43, "90th_percentile": 15.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 21.14, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 21.14, "10th_percentile": 21.14, "90th_percentile": 21.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 39.73, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.73, "10th_percentile": 39.73, "90th_percentile": 39.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 11.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 11.54, "10th_percentile": 11.54, "90th_percentile": 11.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 11.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 11.54, "10th_percentile": 11.54, "90th_percentile": 11.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 60.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 60.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 34.23, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.23, "10th_percentile": 34.23, "90th_percentile": 34.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.34, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.34, "10th_percentile": 38.34, "90th_percentile": 38.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 39.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 39.58, "10th_percentile": 39.58, "90th_percentile": 39.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 49.51, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.51, "10th_percentile": 49.51, "90th_percentile": 49.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 40.74, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.74, "10th_percentile": 40.74, "90th_percentile": 40.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 33.96, "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": 33.96, "10th_percentile": 33.96, "90th_percentile": 33.96, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 60.75, "10th_percentile": 60.75, "90th_percentile": 60.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 60.75, "10th_percentile": 60.75, "90th_percentile": 60.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 60.75, "10th_percentile": 60.75, "90th_percentile": 60.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 60.75, "10th_percentile": 60.75, "90th_percentile": 60.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 60.75, "10th_percentile": 60.75, "90th_percentile": 60.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 60.75, "10th_percentile": 60.75, "90th_percentile": 60.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "CHOLECALCIFEROL (VITAMIN D3) 25 MCG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-82640", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "20555-0033-00", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.43, "maximum": 2.25, "setting": "outpatient", "gross_charge": 2.25, "discounted_cash": 1.57, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 0.78, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.27, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1.91, "10th_percentile": 1.91, "90th_percentile": 1.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1.22, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1.52, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1.52, "10th_percentile": 1.52, "90th_percentile": 1.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1.97, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.42, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.42, "10th_percentile": 1.42, "90th_percentile": 1.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1.09, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.26, "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": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "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": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.57, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 0.57, "10th_percentile": 0.57, "90th_percentile": 0.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1.01, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1.01, "10th_percentile": 1.01, "90th_percentile": 1.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.51, "10th_percentile": 1.51, "90th_percentile": 1.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.51, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.51, "10th_percentile": 1.51, "90th_percentile": 1.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.83, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.83, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "CISPLATIN 1 MG/ML IV SOLN", "drug_information": { "unit": 100.0, "type": "ML" }, "code_information": [ { "code": "RX-9612", "type": "CDM" }, { "code": "J9060", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "16729-0288-38", "type": "NDC" } ], "standard_charges": [ { "minimum": 98.58, "maximum": 1428.75, "setting": "outpatient", "gross_charge": 1428.75, "discounted_cash": 1000.12, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 271.46, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 271.46, "10th_percentile": 271.46, "90th_percentile": 271.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 271.46, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 271.46, "10th_percentile": 271.46, "90th_percentile": 271.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 271.46, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 271.46, "10th_percentile": 271.46, "90th_percentile": 271.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 900.11, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 900.11, "10th_percentile": 900.11, "90th_percentile": 900.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1167.29, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1167.29, "10th_percentile": 1167.29, "90th_percentile": 1167.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 798.67, "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": 798.67, "10th_percentile": 798.67, "90th_percentile": 798.67, "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": "VWH BCBS HMO", "standard_charge_dollar": 930.83, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 930.83, "10th_percentile": 930.83, "90th_percentile": 930.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 862.97, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 862.97, "10th_percentile": 862.97, "90th_percentile": 862.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 862.97, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 862.97, "10th_percentile": 862.97, "90th_percentile": 862.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1428.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1428.75, "10th_percentile": 1428.75, "90th_percentile": 1428.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1428.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1428.75, "10th_percentile": 1428.75, "90th_percentile": 1428.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1214.44, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1214.44, "10th_percentile": 1214.44, "90th_percentile": 1214.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1250.16, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1250.16, "10th_percentile": 1250.16, "90th_percentile": 1250.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1428.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1428.75, "10th_percentile": 1428.75, "90th_percentile": 1428.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 642.94, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 642.94, "10th_percentile": 642.94, "90th_percentile": 642.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1143.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1143.0, "10th_percentile": 1143.0, "90th_percentile": 1143.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 930.83, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 930.83, "10th_percentile": 930.83, "90th_percentile": 930.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 776.53, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 776.53, "10th_percentile": 776.53, "90th_percentile": 776.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 962.98, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 962.98, "10th_percentile": 962.98, "90th_percentile": 962.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1071.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1071.56, "10th_percentile": 1071.56, "90th_percentile": 1071.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1167.29, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1167.29, "10th_percentile": 1167.29, "90th_percentile": 1167.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 497.21, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 497.21, "10th_percentile": 497.21, "90th_percentile": 497.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 98.58, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 98.58, "10th_percentile": 98.58, "90th_percentile": 98.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 98.58, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 98.58, "10th_percentile": 98.58, "90th_percentile": 98.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 98.58, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 98.58, "10th_percentile": 98.58, "90th_percentile": 98.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 98.58, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 98.58, "10th_percentile": 98.58, "90th_percentile": 98.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 98.58, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 98.58, "10th_percentile": 98.58, "90th_percentile": 98.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 98.58, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 98.58, "10th_percentile": 98.58, "90th_percentile": 98.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CLONAZEPAM 0.5 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9637", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "16729-0136-00", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.38, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.97, "10th_percentile": 0.97, "90th_percentile": 0.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 0.9, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.3, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.3, "10th_percentile": 1.3, "90th_percentile": 1.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1.75, "10th_percentile": 1.75, "90th_percentile": 1.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1.35, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.63, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1.09, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1.09, "10th_percentile": 1.09, "90th_percentile": 1.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1.34, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.34, "10th_percentile": 1.34, "90th_percentile": 1.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1.39, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.39, "10th_percentile": 1.39, "90th_percentile": 1.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.51, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 0.51, "10th_percentile": 0.51, "90th_percentile": 0.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 0.7, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1.31, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.31, "10th_percentile": 1.31, "90th_percentile": 1.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.13, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.3, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.3, "10th_percentile": 1.3, "90th_percentile": 1.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.63, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.34, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.34, "10th_percentile": 1.34, "90th_percentile": 1.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.12, "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": 1.12, "10th_percentile": 1.12, "90th_percentile": 1.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "CLONIDINE HCL 0.05 MG ORAL HALF TAB", "drug_information": { "unit": 0.05, "type": "ME" }, "code_information": [ { "code": "RX-4080000020", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00000-0100-20", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.05, "maximum": 5.5, "setting": "outpatient", "gross_charge": 5.5, "discounted_cash": 3.85, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4.48, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": "VWH BCBS HMO", "standard_charge_dollar": 3.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3.58, "10th_percentile": 3.58, "90th_percentile": 3.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.1, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.47, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.47, "10th_percentile": 3.47, "90th_percentile": 3.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.69, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH 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": "VWH 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1.05, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1.05, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.4, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1.91, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1.91, "10th_percentile": 1.91, "90th_percentile": 1.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3.81, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3.6, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3.68, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.68, "10th_percentile": 3.68, "90th_percentile": 3.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2.76, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.76, "10th_percentile": 2.76, "90th_percentile": 2.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3.71, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3.71, "10th_percentile": 3.71, "90th_percentile": 3.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.49, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.49, "10th_percentile": 2.49, "90th_percentile": 2.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2.66, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 4.68, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 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 Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2.48, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient 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": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4.81, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4.81, "10th_percentile": 4.81, "90th_percentile": 4.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 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": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2.99, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2.99, "10th_percentile": 2.99, "90th_percentile": 2.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1.05, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3.58, "10th_percentile": 3.58, "90th_percentile": 3.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4.48, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "CLONIDINE HCL 0.1 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-1755", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0113-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.09, "maximum": 11.0, "setting": "outpatient", "gross_charge": 11.0, "discounted_cash": 7.7, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 2.09, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2.09, "10th_percentile": 2.09, "90th_percentile": 2.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 8.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 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": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 5.31, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.31, "10th_percentile": 5.31, "90th_percentile": 5.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 4.98, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.98, "10th_percentile": 4.98, "90th_percentile": 4.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 8.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient 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": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 4.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 7.17, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 7.17, "10th_percentile": 7.17, "90th_percentile": 7.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 9.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 9.63, "10th_percentile": 9.63, "90th_percentile": 9.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 7.41, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 7.41, "10th_percentile": 7.41, "90th_percentile": 7.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 8.97, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 9.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 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 Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 5.98, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 5.98, "10th_percentile": 5.98, "90th_percentile": 5.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 5.52, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.52, "10th_percentile": 5.52, "90th_percentile": 5.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 7.36, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.36, "10th_percentile": 7.36, "90th_percentile": 7.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 7.62, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.79, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 3.83, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 7.19, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 2.09, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2.09, "10th_percentile": 2.09, "90th_percentile": 2.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2.09, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2.09, "10th_percentile": 2.09, "90th_percentile": 2.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH 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": "MULTIPLAN/PHCS [142]", "plan_name": "VWH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.2, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.94, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.94, "10th_percentile": 6.94, "90th_percentile": 6.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 7.17, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 7.17, "10th_percentile": 7.17, "90th_percentile": 7.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 8.97, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7.38, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "VWH ILLINOIS MEDICAID", "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": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "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" } ] } ] }, { "description": "CLOSURE WND SKN STRP REINF ANT", "code_information": [ { "code": "SUP-155601", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 3.38, "maximum": 17.81, "setting": "outpatient", "gross_charge": 17.81, "discounted_cash": 12.47, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.81, "10th_percentile": 17.81, "90th_percentile": 17.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.81, "10th_percentile": 17.81, "90th_percentile": 17.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.81, "10th_percentile": 17.81, "90th_percentile": 17.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.81, "10th_percentile": 17.81, "90th_percentile": 17.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.81, "10th_percentile": 17.81, "90th_percentile": 17.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.81, "10th_percentile": 17.81, "90th_percentile": 17.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 3.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 15.58, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 15.58, "10th_percentile": 15.58, "90th_percentile": 15.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 12.0, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 14.52, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.52, "10th_percentile": 14.52, "90th_percentile": 14.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 8.07, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.07, "10th_percentile": 8.07, "90th_percentile": 8.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 8.01, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 8.01, "10th_percentile": 8.01, "90th_percentile": 8.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 15.14, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 15.14, "10th_percentile": 15.14, "90th_percentile": 15.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 8.6, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.6, "10th_percentile": 8.6, "90th_percentile": 8.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 11.6, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 14.25, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 14.25, "10th_percentile": 14.25, "90th_percentile": 14.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 9.68, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 9.68, "10th_percentile": 9.68, "90th_percentile": 9.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 13.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 13.36, "10th_percentile": 13.36, "90th_percentile": 13.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 17.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 17.81, "10th_percentile": 17.81, "90th_percentile": 17.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 11.91, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.91, "10th_percentile": 11.91, "90th_percentile": 11.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 8.94, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.94, "10th_percentile": 8.94, "90th_percentile": 8.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.52, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 4.52, "10th_percentile": 4.52, "90th_percentile": 4.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 12.34, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.34, "10th_percentile": 12.34, "90th_percentile": 12.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 6.2, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 6.2, "10th_percentile": 6.2, "90th_percentile": 6.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 11.65, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.65, "10th_percentile": 11.65, "90th_percentile": 11.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.81, "10th_percentile": 17.81, "90th_percentile": 17.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.81, "10th_percentile": 17.81, "90th_percentile": 17.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9.96, "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": 9.96, "10th_percentile": 9.96, "90th_percentile": 9.96, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10.04, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.04, "10th_percentile": 10.04, "90th_percentile": 10.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11.94, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.94, "10th_percentile": 11.94, "90th_percentile": 11.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 14.52, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.52, "10th_percentile": 14.52, "90th_percentile": 14.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 11.24, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.24, "10th_percentile": 11.24, "90th_percentile": 11.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 11.6, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % TOP CREA", "drug_information": { "unit": 15.0, "type": "GR" }, "code_information": [ { "code": "RX-29424", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "51672-4048-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.77, "maximum": 283.0, "setting": "outpatient", "gross_charge": 283.0, "discounted_cash": 198.1, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 283.0, "10th_percentile": 283.0, "90th_percentile": 283.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 283.0, "10th_percentile": 283.0, "90th_percentile": 283.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 283.0, "10th_percentile": 283.0, "90th_percentile": 283.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 283.0, "10th_percentile": 283.0, "90th_percentile": 283.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 283.0, "10th_percentile": 283.0, "90th_percentile": 283.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 283.0, "10th_percentile": 283.0, "90th_percentile": 283.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 185.08, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 185.08, "10th_percentile": 185.08, "90th_percentile": 185.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 196.12, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 196.12, "10th_percentile": 196.12, "90th_percentile": 196.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 98.48, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 98.48, "10th_percentile": 98.48, "90th_percentile": 98.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 71.88, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 71.88, "10th_percentile": 71.88, "90th_percentile": 71.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 53.77, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 53.77, "10th_percentile": 53.77, "90th_percentile": 53.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 184.37, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 184.37, "10th_percentile": 184.37, "90th_percentile": 184.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 230.65, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 230.65, "10th_percentile": 230.65, "90th_percentile": 230.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 53.77, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 53.77, "10th_percentile": 53.77, "90th_percentile": 53.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 189.78, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 189.78, "10th_percentile": 189.78, "90th_percentile": 189.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 178.6, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.6, "10th_percentile": 178.6, "90th_percentile": 178.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 159.47, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 159.47, "10th_percentile": 159.47, "90th_percentile": 159.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 184.37, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 184.37, "10th_percentile": 184.37, "90th_percentile": 184.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 158.2, "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": 158.2, "10th_percentile": 158.2, "90th_percentile": 158.2, "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": "VWH BCBS PPO", "standard_charge_dollar": 230.65, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 230.65, "10th_percentile": 230.65, "90th_percentile": 230.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 190.74, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 190.74, "10th_percentile": 190.74, "90th_percentile": 190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 128.2, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 128.2, "10th_percentile": 128.2, "90th_percentile": 128.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 136.69, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 136.69, "10th_percentile": 136.69, "90th_percentile": 136.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 283.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 283.0, "10th_percentile": 283.0, "90th_percentile": 283.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 283.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 283.0, "10th_percentile": 283.0, "90th_percentile": 283.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 53.77, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 53.77, "10th_percentile": 53.77, "90th_percentile": 53.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 240.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 240.55, "10th_percentile": 240.55, "90th_percentile": 240.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 127.35, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 127.35, "10th_percentile": 127.35, "90th_percentile": 127.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 212.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 212.25, "10th_percentile": 212.25, "90th_percentile": 212.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 247.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 247.63, "10th_percentile": 247.63, "90th_percentile": 247.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 226.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 226.4, "10th_percentile": 226.4, "90th_percentile": 226.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 153.81, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 153.81, "10th_percentile": 153.81, "90th_percentile": 153.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 142.07, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 142.07, "10th_percentile": 142.07, "90th_percentile": 142.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 189.33, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 189.33, "10th_percentile": 189.33, "90th_percentile": 189.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 283.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 283.0, "10th_percentile": 283.0, "90th_percentile": 283.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "CONJUGATED ESTROGENS 0.625 MG/GRAM VAGL CREA", "drug_information": { "unit": 30.0, "type": "GR" }, "code_information": [ { "code": "RX-86460", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00046-0872-21", "type": "NDC" } ], "standard_charges": [ { "minimum": 644.53, "maximum": 3392.25, "setting": "outpatient", "gross_charge": 3392.25, "discounted_cash": 2374.57, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3392.25, "10th_percentile": 3392.25, "90th_percentile": 3392.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3392.25, "10th_percentile": 3392.25, "90th_percentile": 3392.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3392.25, "10th_percentile": 3392.25, "90th_percentile": 3392.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3392.25, "10th_percentile": 3392.25, "90th_percentile": 3392.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3392.25, "10th_percentile": 3392.25, "90th_percentile": 3392.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3392.25, "10th_percentile": 3392.25, "90th_percentile": 3392.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2764.68, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2764.68, "10th_percentile": 2764.68, "90th_percentile": 2764.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1896.27, "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": 1896.27, "10th_percentile": 1896.27, "90th_percentile": 1896.27, "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": "VWH BCBS HMO", "standard_charge_dollar": 2210.05, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2210.05, "10th_percentile": 2210.05, "90th_percentile": 2210.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1911.53, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1911.53, "10th_percentile": 1911.53, "90th_percentile": 1911.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2140.85, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2140.85, "10th_percentile": 2140.85, "90th_percentile": 2140.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2274.84, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2274.84, "10th_percentile": 2274.84, "90th_percentile": 2274.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2218.53, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2218.53, "10th_percentile": 2218.53, "90th_percentile": 2218.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2350.83, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2350.83, "10th_percentile": 2350.83, "90th_percentile": 2350.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1180.5, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1180.5, "10th_percentile": 1180.5, "90th_percentile": 1180.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 861.63, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 861.63, "10th_percentile": 861.63, "90th_percentile": 861.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 644.53, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 644.53, "10th_percentile": 644.53, "90th_percentile": 644.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2210.05, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2210.05, "10th_percentile": 2210.05, "90th_percentile": 2210.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2764.68, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2764.68, "10th_percentile": 2764.68, "90th_percentile": 2764.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 644.53, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 644.53, "10th_percentile": 644.53, "90th_percentile": 644.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2286.38, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2286.38, "10th_percentile": 2286.38, "90th_percentile": 2286.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1536.69, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1536.69, "10th_percentile": 1536.69, "90th_percentile": 1536.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1638.46, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1638.46, "10th_percentile": 1638.46, "90th_percentile": 1638.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 644.53, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 644.53, "10th_percentile": 644.53, "90th_percentile": 644.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3392.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3392.25, "10th_percentile": 3392.25, "90th_percentile": 3392.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3392.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3392.25, "10th_percentile": 3392.25, "90th_percentile": 3392.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2883.41, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2883.41, "10th_percentile": 2883.41, "90th_percentile": 2883.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1526.51, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1526.51, "10th_percentile": 1526.51, "90th_percentile": 1526.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2544.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2544.19, "10th_percentile": 2544.19, "90th_percentile": 2544.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2968.22, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2968.22, "10th_percentile": 2968.22, "90th_percentile": 2968.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2713.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2713.8, "10th_percentile": 2713.8, "90th_percentile": 2713.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1843.69, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1843.69, "10th_percentile": 1843.69, "90th_percentile": 1843.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1702.91, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1702.91, "10th_percentile": 1702.91, "90th_percentile": 1702.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2269.42, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2269.42, "10th_percentile": 2269.42, "90th_percentile": 2269.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3392.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3392.25, "10th_percentile": 3392.25, "90th_percentile": 3392.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "COTTONOID 1 X 3 IN (80-1408)", "code_information": [ { "code": "SUP-9012020", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 3.48, "maximum": 18.29, "setting": "outpatient", "gross_charge": 18.29, "discounted_cash": 12.8, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 3.48, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3.48, "10th_percentile": 3.48, "90th_percentile": 3.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 16.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 12.33, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 12.33, "10th_percentile": 12.33, "90th_percentile": 12.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 14.91, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.91, "10th_percentile": 14.91, "90th_percentile": 14.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 8.29, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.29, "10th_percentile": 8.29, "90th_percentile": 8.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 8.23, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 8.23, "10th_percentile": 8.23, "90th_percentile": 8.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 15.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 15.55, "10th_percentile": 15.55, "90th_percentile": 15.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 8.83, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.83, "10th_percentile": 8.83, "90th_percentile": 8.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 11.92, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 11.92, "10th_percentile": 11.92, "90th_percentile": 11.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 14.63, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 14.63, "10th_percentile": 14.63, "90th_percentile": 14.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 9.94, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 9.94, "10th_percentile": 9.94, "90th_percentile": 9.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 13.72, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 13.72, "10th_percentile": 13.72, "90th_percentile": 13.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 18.29, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 12.24, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.24, "10th_percentile": 12.24, "90th_percentile": 12.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 9.18, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.18, "10th_percentile": 9.18, "90th_percentile": 9.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.65, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 4.65, "10th_percentile": 4.65, "90th_percentile": 4.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 12.67, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.67, "10th_percentile": 12.67, "90th_percentile": 12.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 6.36, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% 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 Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 11.96, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.96, "10th_percentile": 11.96, "90th_percentile": 11.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.29, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.29, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3.48, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 3.48, "10th_percentile": 3.48, "90th_percentile": 3.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3.48, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 3.48, "10th_percentile": 3.48, "90th_percentile": 3.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 10.22, "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": 10.22, "10th_percentile": 10.22, "90th_percentile": 10.22, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10.31, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.31, "10th_percentile": 10.31, "90th_percentile": 10.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 12.27, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.27, "10th_percentile": 12.27, "90th_percentile": 12.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 14.91, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.91, "10th_percentile": 14.91, "90th_percentile": 14.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 11.54, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.54, "10th_percentile": 11.54, "90th_percentile": 11.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 11.92, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 11.92, "10th_percentile": 11.92, "90th_percentile": 11.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "COVID VAC 25-26(6M-11Y)(MOD)PF 25 MCG/0.25 ML IM SYRG", "drug_information": { "unit": 0.25, "type": "ML" }, "code_information": [ { "code": "RX-251279", "type": "CDM" }, { "code": "91321", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "80777-0113-80", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.83, "maximum": 99.0, "setting": "outpatient", "gross_charge": 99.0, "discounted_cash": 69.3, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 18.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 18.81, "10th_percentile": 18.81, "90th_percentile": 18.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 80.69, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.69, "10th_percentile": 80.69, "90th_percentile": 80.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 55.79, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.79, "10th_percentile": 55.79, "90th_percentile": 55.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 62.48, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.48, "10th_percentile": 62.48, "90th_percentile": 62.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 66.39, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.39, "10th_percentile": 66.39, "90th_percentile": 66.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 55.34, "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": 55.34, "10th_percentile": 55.34, "90th_percentile": 55.34, "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": "VWH BCBS HMO", "standard_charge_dollar": 64.5, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 64.5, "10th_percentile": 64.5, "90th_percentile": 64.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 99.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 99.0, "10th_percentile": 99.0, "90th_percentile": 99.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 99.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 99.0, "10th_percentile": 99.0, "90th_percentile": 99.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 84.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 84.15, "10th_percentile": 84.15, "90th_percentile": 84.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 86.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 86.63, "10th_percentile": 86.63, "90th_percentile": 86.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 25.15, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 25.15, "10th_percentile": 25.15, "90th_percentile": 25.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 99.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 99.0, "10th_percentile": 99.0, "90th_percentile": 99.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 44.55, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 44.55, "10th_percentile": 44.55, "90th_percentile": 44.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 79.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 79.2, "10th_percentile": 79.2, "90th_percentile": 79.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 64.5, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 64.5, "10th_percentile": 64.5, "90th_percentile": 64.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 53.81, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 53.81, "10th_percentile": 53.81, "90th_percentile": 53.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 66.73, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 66.73, "10th_percentile": 66.73, "90th_percentile": 66.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 74.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 74.25, "10th_percentile": 74.25, "90th_percentile": 74.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 34.45, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 34.45, "10th_percentile": 34.45, "90th_percentile": 34.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 18.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 18.81, "10th_percentile": 18.81, "90th_percentile": 18.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 18.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 18.81, "10th_percentile": 18.81, "90th_percentile": 18.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 68.61, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.61, "10th_percentile": 68.61, "90th_percentile": 68.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 64.75, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.75, "10th_percentile": 64.75, "90th_percentile": 64.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 80.69, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.69, "10th_percentile": 80.69, "90th_percentile": 80.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.83, "10th_percentile": 6.83, "90th_percentile": 6.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.83, "10th_percentile": 6.83, "90th_percentile": 6.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.83, "10th_percentile": 6.83, "90th_percentile": 6.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.83, "10th_percentile": 6.83, "90th_percentile": 6.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.83, "10th_percentile": 6.83, "90th_percentile": 6.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.83, "10th_percentile": 6.83, "90th_percentile": 6.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-179322", "type": "CDM" }, { "code": "J9100", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "61703-0305-38", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.96, "maximum": 231.25, "setting": "outpatient", "gross_charge": 231.25, "discounted_cash": 161.87, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 43.94, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 43.94, "10th_percentile": 43.94, "90th_percentile": 43.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 43.94, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 43.94, "10th_percentile": 43.94, "90th_percentile": 43.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 43.94, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 43.94, "10th_percentile": 43.94, "90th_percentile": 43.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 145.69, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.69, "10th_percentile": 145.69, "90th_percentile": 145.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 188.93, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.93, "10th_percentile": 188.93, "90th_percentile": 188.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 129.27, "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": 129.27, "10th_percentile": 129.27, "90th_percentile": 129.27, "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": "VWH BCBS HMO", "standard_charge_dollar": 150.66, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 150.66, "10th_percentile": 150.66, "90th_percentile": 150.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 139.68, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.68, "10th_percentile": 139.68, "90th_percentile": 139.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 139.68, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.68, "10th_percentile": 139.68, "90th_percentile": 139.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 231.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 231.25, "10th_percentile": 231.25, "90th_percentile": 231.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 231.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 231.25, "10th_percentile": 231.25, "90th_percentile": 231.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 196.56, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 196.56, "10th_percentile": 196.56, "90th_percentile": 196.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 202.34, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 202.34, "10th_percentile": 202.34, "90th_percentile": 202.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 58.74, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 58.74, "10th_percentile": 58.74, "90th_percentile": 58.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 231.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 231.25, "10th_percentile": 231.25, "90th_percentile": 231.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 104.06, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 104.06, "10th_percentile": 104.06, "90th_percentile": 104.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 185.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 185.0, "10th_percentile": 185.0, "90th_percentile": 185.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 150.66, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 150.66, "10th_percentile": 150.66, "90th_percentile": 150.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 125.68, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 125.68, "10th_percentile": 125.68, "90th_percentile": 125.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 155.86, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 155.86, "10th_percentile": 155.86, "90th_percentile": 155.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 173.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 173.44, "10th_percentile": 173.44, "90th_percentile": 173.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 188.93, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.93, "10th_percentile": 188.93, "90th_percentile": 188.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 80.48, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 80.48, "10th_percentile": 80.48, "90th_percentile": 80.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.96, "10th_percentile": 15.96, "90th_percentile": 15.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.96, "10th_percentile": 15.96, "90th_percentile": 15.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.96, "10th_percentile": 15.96, "90th_percentile": 15.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.96, "10th_percentile": 15.96, "90th_percentile": 15.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.96, "10th_percentile": 15.96, "90th_percentile": 15.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 15.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 15.96, "10th_percentile": 15.96, "90th_percentile": 15.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "DANTROLENE 25 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9718", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00115-4411-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.75, "maximum": 35.5, "setting": "outpatient", "gross_charge": 35.5, "discounted_cash": 24.85, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 6.75, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 28.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 28.4, "10th_percentile": 28.4, "90th_percentile": 28.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 17.15, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.15, "10th_percentile": 17.15, "90th_percentile": 17.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 16.08, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 26.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 26.63, "10th_percentile": 26.63, "90th_percentile": 26.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 15.98, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 15.98, "10th_percentile": 15.98, "90th_percentile": 15.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 23.13, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 23.13, "10th_percentile": 23.13, "90th_percentile": 23.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 31.06, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 31.06, "10th_percentile": 31.06, "90th_percentile": 31.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 23.93, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 23.93, "10th_percentile": 23.93, "90th_percentile": 23.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 28.93, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.93, "10th_percentile": 28.93, "90th_percentile": 28.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 30.18, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 30.18, "10th_percentile": 30.18, "90th_percentile": 30.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 19.29, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 19.29, "10th_percentile": 19.29, "90th_percentile": 19.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 17.82, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.82, "10th_percentile": 17.82, "90th_percentile": 17.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 35.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 35.5, "10th_percentile": 35.5, "90th_percentile": 35.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 23.75, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.75, "10th_percentile": 23.75, "90th_percentile": 23.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 24.6, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.6, "10th_percentile": 24.6, "90th_percentile": 24.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 9.02, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 9.02, "10th_percentile": 9.02, "90th_percentile": 9.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 12.35, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 12.35, "10th_percentile": 12.35, "90th_percentile": 12.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 23.22, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.22, "10th_percentile": 23.22, "90th_percentile": 23.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 6.75, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 6.75, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 35.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 35.5, "10th_percentile": 35.5, "90th_percentile": 35.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 35.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 35.5, "10th_percentile": 35.5, "90th_percentile": 35.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 20.0, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 22.4, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.4, "10th_percentile": 22.4, "90th_percentile": 22.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 23.13, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 23.13, "10th_percentile": 23.13, "90th_percentile": 23.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 28.93, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.93, "10th_percentile": 28.93, "90th_percentile": 28.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 23.81, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.81, "10th_percentile": 23.81, "90th_percentile": 23.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 19.84, "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": 19.84, "10th_percentile": 19.84, "90th_percentile": 19.84, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.5, "10th_percentile": 35.5, "90th_percentile": 35.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.5, "10th_percentile": 35.5, "90th_percentile": 35.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.5, "10th_percentile": 35.5, "90th_percentile": 35.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.5, "10th_percentile": 35.5, "90th_percentile": 35.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.5, "10th_percentile": 35.5, "90th_percentile": 35.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 35.5, "10th_percentile": 35.5, "90th_percentile": 35.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "DECLOG MIXTURE (KH)", "drug_information": { "unit": 10.0, "type": "ML" }, "code_information": [ { "code": "RX-212765", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00000-1004-86", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.14, "maximum": 6.0, "setting": "outpatient", "gross_charge": 6.0, "discounted_cash": 4.2, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "VWH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "VWH BCBS PPO", "standard_charge_dollar": 4.89, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.89, "10th_percentile": 4.89, "90th_percentile": 4.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.02, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.02, "10th_percentile": 4.02, "90th_percentile": 4.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.79, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.79, "10th_percentile": 3.79, "90th_percentile": 3.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.38, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3.91, "10th_percentile": 3.91, "90th_percentile": 3.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH 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": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1.14, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1.14, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.52, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1.52, "10th_percentile": 1.52, "90th_percentile": 1.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2.09, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2.09, "10th_percentile": 2.09, "90th_percentile": 2.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 4.16, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.16, "10th_percentile": 4.16, "90th_percentile": 4.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3.92, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.92, "10th_percentile": 3.92, "90th_percentile": 3.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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": "VWH UHC CORE", "standard_charge_dollar": 3.01, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.01, "10th_percentile": 3.01, "90th_percentile": 3.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 4.01, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.01, "10th_percentile": 4.01, "90th_percentile": 4.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 4.04, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 4.04, "10th_percentile": 4.04, "90th_percentile": 4.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 5.1, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 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 Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 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": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3.91, "10th_percentile": 3.91, "90th_percentile": 3.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2.7, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2.9, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.9, "10th_percentile": 2.9, "90th_percentile": 2.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4.89, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.89, "10th_percentile": 4.89, "90th_percentile": 4.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient 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": "Outpatient Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.72, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.72, "10th_percentile": 2.72, "90th_percentile": 2.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 5.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% 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; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3.26, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3.26, "10th_percentile": 3.26, "90th_percentile": 3.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1.14, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "DEXTROSE 5 % IN WATER (D5W) IV SOLP", "drug_information": { "unit": 500.0, "type": "ML" }, "code_information": [ { "code": "RX-2364", "type": "CDM" }, { "code": "J7060", "type": "HCPCS" }, { "code": "0258", "type": "RC" }, { "code": "00264-7510-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.54, "maximum": 297.75, "setting": "outpatient", "gross_charge": 297.75, "discounted_cash": 208.42, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 103.62, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 103.62, "10th_percentile": 103.62, "90th_percentile": 103.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 75.63, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 75.63, "10th_percentile": 75.63, "90th_percentile": 75.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 56.57, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 56.57, "10th_percentile": 56.57, "90th_percentile": 56.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 193.98, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 193.98, "10th_percentile": 193.98, "90th_percentile": 193.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 243.26, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.26, "10th_percentile": 243.26, "90th_percentile": 243.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 56.57, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 56.57, "10th_percentile": 56.57, "90th_percentile": 56.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 179.84, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.84, "10th_percentile": 179.84, "90th_percentile": 179.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 187.58, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.58, "10th_percentile": 187.58, "90th_percentile": 187.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 179.84, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.84, "10th_percentile": 179.84, "90th_percentile": 179.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 193.98, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 193.98, "10th_percentile": 193.98, "90th_percentile": 193.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 166.44, "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": 166.44, "10th_percentile": 166.44, "90th_percentile": 166.44, "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": "VWH BCBS PPO", "standard_charge_dollar": 243.26, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.26, "10th_percentile": 243.26, "90th_percentile": 243.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual 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": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.54, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.54, "10th_percentile": 20.54, "90th_percentile": 20.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 200.68, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 200.68, "10th_percentile": 200.68, "90th_percentile": 200.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.54, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.54, "10th_percentile": 20.54, "90th_percentile": 20.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.54, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.54, "10th_percentile": 20.54, "90th_percentile": 20.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.54, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.54, "10th_percentile": 20.54, "90th_percentile": 20.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 56.57, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 56.57, "10th_percentile": 56.57, "90th_percentile": 56.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.54, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.54, "10th_percentile": 20.54, "90th_percentile": 20.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 253.09, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 253.09, "10th_percentile": 253.09, "90th_percentile": 253.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 133.99, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 133.99, "10th_percentile": 133.99, "90th_percentile": 133.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 223.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 223.31, "10th_percentile": 223.31, "90th_percentile": 223.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.54, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 20.54, "10th_percentile": 20.54, "90th_percentile": 20.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 260.53, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 260.53, "10th_percentile": 260.53, "90th_percentile": 260.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 238.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 238.2, "10th_percentile": 238.2, "90th_percentile": 238.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 161.83, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 161.83, "10th_percentile": 161.83, "90th_percentile": 161.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 149.47, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.47, "10th_percentile": 149.47, "90th_percentile": 149.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 199.19, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 199.19, "10th_percentile": 199.19, "90th_percentile": 199.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 297.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 297.75, "10th_percentile": 297.75, "90th_percentile": 297.75, "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": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 297.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 297.75, "10th_percentile": 297.75, "90th_percentile": 297.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 297.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 297.75, "10th_percentile": 297.75, "90th_percentile": 297.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "DIAZEPAM 5 MG/ML INJ SYRG", "drug_information": { "unit": 2.0, "type": "ML" }, "code_information": [ { "code": "RX-91486", "type": "CDM" }, { "code": "J3360", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-1273-03", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.34, "maximum": 468.75, "setting": "outpatient", "gross_charge": 468.75, "discounted_cash": 328.12, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 89.06, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 89.06, "10th_percentile": 89.06, "90th_percentile": 89.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 89.06, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 89.06, "10th_percentile": 89.06, "90th_percentile": 89.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 89.06, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 89.06, "10th_percentile": 89.06, "90th_percentile": 89.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 295.31, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.31, "10th_percentile": 295.31, "90th_percentile": 295.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 382.97, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 382.97, "10th_percentile": 382.97, "90th_percentile": 382.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 262.03, "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": 262.03, "10th_percentile": 262.03, "90th_percentile": 262.03, "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": "VWH BCBS HMO", "standard_charge_dollar": 305.39, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 305.39, "10th_percentile": 305.39, "90th_percentile": 305.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 283.13, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 283.13, "10th_percentile": 283.13, "90th_percentile": 283.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 283.13, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 283.13, "10th_percentile": 283.13, "90th_percentile": 283.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 468.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 468.75, "10th_percentile": 468.75, "90th_percentile": 468.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 468.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 468.75, "10th_percentile": 468.75, "90th_percentile": 468.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 398.44, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 398.44, "10th_percentile": 398.44, "90th_percentile": 398.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 410.16, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 410.16, "10th_percentile": 410.16, "90th_percentile": 410.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 119.06, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 119.06, "10th_percentile": 119.06, "90th_percentile": 119.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 468.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 468.75, "10th_percentile": 468.75, "90th_percentile": 468.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 210.94, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 210.94, "10th_percentile": 210.94, "90th_percentile": 210.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 375.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 375.0, "10th_percentile": 375.0, "90th_percentile": 375.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 305.39, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 305.39, "10th_percentile": 305.39, "90th_percentile": 305.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 254.77, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 254.77, "10th_percentile": 254.77, "90th_percentile": 254.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 315.94, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 315.94, "10th_percentile": 315.94, "90th_percentile": 315.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 351.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 351.56, "10th_percentile": 351.56, "90th_percentile": 351.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 382.97, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 382.97, "10th_percentile": 382.97, "90th_percentile": 382.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 163.13, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 163.13, "10th_percentile": 163.13, "90th_percentile": 163.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32.34, "10th_percentile": 32.34, "90th_percentile": 32.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32.34, "10th_percentile": 32.34, "90th_percentile": 32.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32.34, "10th_percentile": 32.34, "90th_percentile": 32.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32.34, "10th_percentile": 32.34, "90th_percentile": 32.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32.34, "10th_percentile": 32.34, "90th_percentile": 32.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 32.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 32.34, "10th_percentile": 32.34, "90th_percentile": 32.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "DILTIAZEM HCL 240 MG ORAL CP24", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-29274", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0217-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.28, "maximum": 17.25, "setting": "outpatient", "gross_charge": 17.25, "discounted_cash": 12.07, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 3.28, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3.28, "10th_percentile": 3.28, "90th_percentile": 3.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 13.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 13.8, "10th_percentile": 13.8, "90th_percentile": 13.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 8.33, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.33, "10th_percentile": 8.33, "90th_percentile": 8.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 7.81, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 12.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 12.94, "10th_percentile": 12.94, "90th_percentile": 12.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 7.76, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 7.76, "10th_percentile": 7.76, "90th_percentile": 7.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 11.24, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 11.24, "10th_percentile": 11.24, "90th_percentile": 11.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 15.09, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 15.09, "10th_percentile": 15.09, "90th_percentile": 15.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 11.63, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 11.63, "10th_percentile": 11.63, "90th_percentile": 11.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 14.06, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 14.66, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 14.66, "10th_percentile": 14.66, "90th_percentile": 14.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 9.38, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 9.38, "10th_percentile": 9.38, "90th_percentile": 9.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 8.66, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.66, "10th_percentile": 8.66, "90th_percentile": 8.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 11.54, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.54, "10th_percentile": 11.54, "90th_percentile": 11.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 11.95, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.95, "10th_percentile": 11.95, "90th_percentile": 11.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.38, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 4.38, "10th_percentile": 4.38, "90th_percentile": 4.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 6.0, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% 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 Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 11.28, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.28, "10th_percentile": 11.28, "90th_percentile": 11.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 3.28, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "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; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3.28, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "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; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9.72, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.72, "10th_percentile": 9.72, "90th_percentile": 9.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10.89, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.89, "10th_percentile": 10.89, "90th_percentile": 10.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 11.24, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 11.24, "10th_percentile": 11.24, "90th_percentile": 11.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 14.06, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11.57, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.57, "10th_percentile": 11.57, "90th_percentile": 11.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9.64, "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": 9.64, "10th_percentile": 9.64, "90th_percentile": 9.64, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "DOXYCYCLINE HYCLATE 50 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-2624", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "50268-0277-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.12, "maximum": 53.25, "setting": "outpatient", "gross_charge": 53.25, "discounted_cash": 37.27, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 10.12, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 10.12, "10th_percentile": 10.12, "90th_percentile": 10.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 42.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 42.6, "10th_percentile": 42.6, "90th_percentile": 42.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 25.72, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 24.12, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.12, "10th_percentile": 24.12, "90th_percentile": 24.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 39.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 39.94, "10th_percentile": 39.94, "90th_percentile": 39.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 23.96, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 34.69, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 34.69, "10th_percentile": 34.69, "90th_percentile": 34.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 46.59, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 46.59, "10th_percentile": 46.59, "90th_percentile": 46.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 35.89, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 35.89, "10th_percentile": 35.89, "90th_percentile": 35.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 43.4, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.4, "10th_percentile": 43.4, "90th_percentile": 43.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 45.26, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 45.26, "10th_percentile": 45.26, "90th_percentile": 45.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 28.94, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 28.94, "10th_percentile": 28.94, "90th_percentile": 28.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 26.73, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.73, "10th_percentile": 26.73, "90th_percentile": 26.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 53.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 53.25, "10th_percentile": 53.25, "90th_percentile": 53.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 35.62, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.62, "10th_percentile": 35.62, "90th_percentile": 35.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 36.9, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.9, "10th_percentile": 36.9, "90th_percentile": 36.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 13.53, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 13.53, "10th_percentile": 13.53, "90th_percentile": 13.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 18.53, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 18.53, "10th_percentile": 18.53, "90th_percentile": 18.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 34.83, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.83, "10th_percentile": 34.83, "90th_percentile": 34.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 10.12, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 10.12, "10th_percentile": 10.12, "90th_percentile": 10.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 10.12, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 10.12, "10th_percentile": 10.12, "90th_percentile": 10.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 53.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 53.25, "10th_percentile": 53.25, "90th_percentile": 53.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 53.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 53.25, "10th_percentile": 53.25, "90th_percentile": 53.25, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 30.01, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 33.61, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.61, "10th_percentile": 33.61, "90th_percentile": 33.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 34.69, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 34.69, "10th_percentile": 34.69, "90th_percentile": 34.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 43.4, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.4, "10th_percentile": 43.4, "90th_percentile": 43.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 35.71, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.71, "10th_percentile": 35.71, "90th_percentile": 35.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 29.77, "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": 29.77, "10th_percentile": 29.77, "90th_percentile": 29.77, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 53.25, "10th_percentile": 53.25, "90th_percentile": 53.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 53.25, "10th_percentile": 53.25, "90th_percentile": 53.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 53.25, "10th_percentile": 53.25, "90th_percentile": 53.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 53.25, "10th_percentile": 53.25, "90th_percentile": 53.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 53.25, "10th_percentile": 53.25, "90th_percentile": 53.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 53.25, "10th_percentile": 53.25, "90th_percentile": 53.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "DOXYCYCLINE HYCLATE 100 MG IV SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-2622", "type": "CDM" }, { "code": "J1271", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "67457-0437-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.59, "maximum": 182.5, "setting": "outpatient", "gross_charge": 182.5, "discounted_cash": 127.75, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 182.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 182.5, "10th_percentile": 182.5, "90th_percentile": 182.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 182.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 182.5, "10th_percentile": 182.5, "90th_percentile": 182.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 149.1, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.1, "10th_percentile": 149.1, "90th_percentile": 149.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH THE ALLIANCE", "standard_charge_dollar": 99.19, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 99.19, "10th_percentile": 99.19, "90th_percentile": 99.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 118.9, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 118.9, "10th_percentile": 118.9, "90th_percentile": 118.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 46.36, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 46.36, "10th_percentile": 46.36, "90th_percentile": 46.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 159.69, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 159.69, "10th_percentile": 159.69, "90th_percentile": 159.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 82.13, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 155.13, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 155.13, "10th_percentile": 155.13, "90th_percentile": 155.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 146.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 146.0, "10th_percentile": 146.0, "90th_percentile": 146.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 182.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 182.5, "10th_percentile": 182.5, "90th_percentile": 182.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 136.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 136.88, "10th_percentile": 136.88, "90th_percentile": 136.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 63.51, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 63.51, "10th_percentile": 63.51, "90th_percentile": 63.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 123.01, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 123.01, "10th_percentile": 123.01, "90th_percentile": 123.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 149.1, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.1, "10th_percentile": 149.1, "90th_percentile": 149.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 114.98, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 114.98, "10th_percentile": 114.98, "90th_percentile": 114.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 118.9, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 118.9, "10th_percentile": 118.9, "90th_percentile": 118.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 102.02, "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": 102.02, "10th_percentile": 102.02, "90th_percentile": 102.02, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 110.23, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 110.23, "10th_percentile": 110.23, "90th_percentile": 110.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 110.23, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 110.23, "10th_percentile": 110.23, "90th_percentile": 110.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 34.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 34.68, "10th_percentile": 34.68, "90th_percentile": 34.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 34.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 34.68, "10th_percentile": 34.68, "90th_percentile": 34.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 34.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 34.68, "10th_percentile": 34.68, "90th_percentile": 34.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 12.59, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 12.59, "10th_percentile": 12.59, "90th_percentile": 12.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 12.59, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 12.59, "10th_percentile": 12.59, "90th_percentile": 12.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 12.59, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 12.59, "10th_percentile": 12.59, "90th_percentile": 12.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 12.59, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 12.59, "10th_percentile": 12.59, "90th_percentile": 12.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 12.59, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 12.59, "10th_percentile": 12.59, "90th_percentile": 12.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 12.59, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 12.59, "10th_percentile": 12.59, "90th_percentile": 12.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "DRAIN BLAKE HUBLESS ROUND 19FR W/O TROCAR SILICONE(ETHICON 2230)", "code_information": [ { "code": "SUP-304460", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 131.11, "maximum": 690.07, "setting": "outpatient", "gross_charge": 690.07, "discounted_cash": 483.05, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 690.07, "10th_percentile": 690.07, "90th_percentile": 690.07, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 690.07, "10th_percentile": 690.07, "90th_percentile": 690.07, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 690.07, "10th_percentile": 690.07, "90th_percentile": 690.07, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 690.07, "10th_percentile": 690.07, "90th_percentile": 690.07, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 690.07, "10th_percentile": 690.07, "90th_percentile": 690.07, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 690.07, "10th_percentile": 690.07, "90th_percentile": 690.07, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 131.11, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 131.11, "10th_percentile": 131.11, "90th_percentile": 131.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 603.81, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 603.81, "10th_percentile": 603.81, "90th_percentile": 603.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 465.11, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 465.11, "10th_percentile": 465.11, "90th_percentile": 465.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 562.41, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 562.41, "10th_percentile": 562.41, "90th_percentile": 562.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 312.6, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 312.6, "10th_percentile": 312.6, "90th_percentile": 312.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 310.53, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 310.53, "10th_percentile": 310.53, "90th_percentile": 310.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 586.56, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 586.56, "10th_percentile": 586.56, "90th_percentile": 586.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 333.3, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 333.3, "10th_percentile": 333.3, "90th_percentile": 333.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 449.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 449.58, "10th_percentile": 449.58, "90th_percentile": 449.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 552.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 552.06, "10th_percentile": 552.06, "90th_percentile": 552.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 375.05, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 375.05, "10th_percentile": 375.05, "90th_percentile": 375.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 517.55, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 517.55, "10th_percentile": 517.55, "90th_percentile": 517.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 690.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 690.07, "10th_percentile": 690.07, "90th_percentile": 690.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 461.66, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 461.66, "10th_percentile": 461.66, "90th_percentile": 461.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 346.42, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 346.42, "10th_percentile": 346.42, "90th_percentile": 346.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 175.28, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 175.28, "10th_percentile": 175.28, "90th_percentile": 175.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 478.22, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 478.22, "10th_percentile": 478.22, "90th_percentile": 478.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 240.14, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 240.14, "10th_percentile": 240.14, "90th_percentile": 240.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 451.31, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 451.31, "10th_percentile": 451.31, "90th_percentile": 451.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 690.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 690.07, "10th_percentile": 690.07, "90th_percentile": 690.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 690.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 690.07, "10th_percentile": 690.07, "90th_percentile": 690.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 131.11, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 131.11, "10th_percentile": 131.11, "90th_percentile": 131.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 131.11, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 131.11, "10th_percentile": 131.11, "90th_percentile": 131.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 385.75, "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": 385.75, "10th_percentile": 385.75, "90th_percentile": 385.75, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 388.85, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 388.85, "10th_percentile": 388.85, "90th_percentile": 388.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 462.76, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 462.76, "10th_percentile": 462.76, "90th_percentile": 462.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 562.41, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 562.41, "10th_percentile": 562.41, "90th_percentile": 562.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 435.5, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 435.5, "10th_percentile": 435.5, "90th_percentile": 435.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 449.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 449.58, "10th_percentile": 449.58, "90th_percentile": 449.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "DRAIN WND FLT RADPQ SURG RELIA 7FR", "code_information": [ { "code": "SUP-9082", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 11.99, "maximum": 63.11, "setting": "outpatient", "gross_charge": 63.11, "discounted_cash": 44.18, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 11.99, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 11.99, "10th_percentile": 11.99, "90th_percentile": 11.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 55.22, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 55.22, "10th_percentile": 55.22, "90th_percentile": 55.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 42.54, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 42.54, "10th_percentile": 42.54, "90th_percentile": 42.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 51.43, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.43, "10th_percentile": 51.43, "90th_percentile": 51.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 28.59, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.59, "10th_percentile": 28.59, "90th_percentile": 28.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 28.4, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 28.4, "10th_percentile": 28.4, "90th_percentile": 28.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 53.64, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 53.64, "10th_percentile": 53.64, "90th_percentile": 53.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 30.48, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.48, "10th_percentile": 30.48, "90th_percentile": 30.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 41.12, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 41.12, "10th_percentile": 41.12, "90th_percentile": 41.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 50.49, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 50.49, "10th_percentile": 50.49, "90th_percentile": 50.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 34.3, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 34.3, "10th_percentile": 34.3, "90th_percentile": 34.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 47.33, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 47.33, "10th_percentile": 47.33, "90th_percentile": 47.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 63.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 42.22, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.22, "10th_percentile": 42.22, "90th_percentile": 42.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 31.68, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.68, "10th_percentile": 31.68, "90th_percentile": 31.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 16.03, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 16.03, "10th_percentile": 16.03, "90th_percentile": 16.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 43.74, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.74, "10th_percentile": 43.74, "90th_percentile": 43.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 21.96, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 21.96, "10th_percentile": 21.96, "90th_percentile": 21.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 41.27, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.27, "10th_percentile": 41.27, "90th_percentile": 41.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 63.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 63.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 63.11, "10th_percentile": 63.11, "90th_percentile": 63.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 11.99, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 11.99, "10th_percentile": 11.99, "90th_percentile": 11.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 11.99, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 11.99, "10th_percentile": 11.99, "90th_percentile": 11.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 35.28, "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": 35.28, "10th_percentile": 35.28, "90th_percentile": 35.28, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 35.56, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 42.32, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.32, "10th_percentile": 42.32, "90th_percentile": 42.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 51.43, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.43, "10th_percentile": 51.43, "90th_percentile": 51.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 39.83, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.83, "10th_percentile": 39.83, "90th_percentile": 39.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 41.12, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 41.12, "10th_percentile": 41.12, "90th_percentile": 41.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "DRESSING MEPILEX AG 4X12", "code_information": [ { "code": "SUP-318809", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 65.82, "maximum": 346.43, "setting": "outpatient", "gross_charge": 346.43, "discounted_cash": 242.5, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 346.43, "10th_percentile": 346.43, "90th_percentile": 346.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 346.43, "10th_percentile": 346.43, "90th_percentile": 346.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 346.43, "10th_percentile": 346.43, "90th_percentile": 346.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 346.43, "10th_percentile": 346.43, "90th_percentile": 346.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 346.43, "10th_percentile": 346.43, "90th_percentile": 346.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 346.43, "10th_percentile": 346.43, "90th_percentile": 346.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 65.82, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 65.82, "10th_percentile": 65.82, "90th_percentile": 65.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 303.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 303.13, "10th_percentile": 303.13, "90th_percentile": 303.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 233.49, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 233.49, "10th_percentile": 233.49, "90th_percentile": 233.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 282.34, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.34, "10th_percentile": 282.34, "90th_percentile": 282.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 156.93, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.93, "10th_percentile": 156.93, "90th_percentile": 156.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 155.89, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 155.89, "10th_percentile": 155.89, "90th_percentile": 155.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 294.47, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 294.47, "10th_percentile": 294.47, "90th_percentile": 294.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 167.33, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 167.33, "10th_percentile": 167.33, "90th_percentile": 167.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 225.7, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 225.7, "10th_percentile": 225.7, "90th_percentile": 225.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 277.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 277.14, "10th_percentile": 277.14, "90th_percentile": 277.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 188.28, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 188.28, "10th_percentile": 188.28, "90th_percentile": 188.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 259.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 259.82, "10th_percentile": 259.82, "90th_percentile": 259.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 346.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 346.43, "10th_percentile": 346.43, "90th_percentile": 346.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 231.76, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 231.76, "10th_percentile": 231.76, "90th_percentile": 231.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 173.91, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 173.91, "10th_percentile": 173.91, "90th_percentile": 173.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 87.99, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 87.99, "10th_percentile": 87.99, "90th_percentile": 87.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 240.08, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 240.08, "10th_percentile": 240.08, "90th_percentile": 240.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 120.56, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 120.56, "10th_percentile": 120.56, "90th_percentile": 120.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 226.57, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 226.57, "10th_percentile": 226.57, "90th_percentile": 226.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 346.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 346.43, "10th_percentile": 346.43, "90th_percentile": 346.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 346.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 346.43, "10th_percentile": 346.43, "90th_percentile": 346.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 65.82, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 65.82, "10th_percentile": 65.82, "90th_percentile": 65.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 65.82, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 65.82, "10th_percentile": 65.82, "90th_percentile": 65.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 193.65, "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": 193.65, "10th_percentile": 193.65, "90th_percentile": 193.65, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 195.21, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 195.21, "10th_percentile": 195.21, "90th_percentile": 195.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 232.32, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 232.32, "10th_percentile": 232.32, "90th_percentile": 232.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 282.34, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.34, "10th_percentile": 282.34, "90th_percentile": 282.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 218.63, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 218.63, "10th_percentile": 218.63, "90th_percentile": 218.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 225.7, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 225.7, "10th_percentile": 225.7, "90th_percentile": 225.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "DRESSING SILV AG ALGIDEX 1/2X5", "code_information": [ { "code": "SUP-319112", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 18.58, "maximum": 97.8, "setting": "outpatient", "gross_charge": 97.8, "discounted_cash": 68.46, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 97.8, "10th_percentile": 97.8, "90th_percentile": 97.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 97.8, "10th_percentile": 97.8, "90th_percentile": 97.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 97.8, "10th_percentile": 97.8, "90th_percentile": 97.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 97.8, "10th_percentile": 97.8, "90th_percentile": 97.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 97.8, "10th_percentile": 97.8, "90th_percentile": 97.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 97.8, "10th_percentile": 97.8, "90th_percentile": 97.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 18.58, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 18.58, "10th_percentile": 18.58, "90th_percentile": 18.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 85.58, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 85.58, "10th_percentile": 85.58, "90th_percentile": 85.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 65.92, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 65.92, "10th_percentile": 65.92, "90th_percentile": 65.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 79.71, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.71, "10th_percentile": 79.71, "90th_percentile": 79.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 44.3, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.3, "10th_percentile": 44.3, "90th_percentile": 44.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 44.01, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 44.01, "10th_percentile": 44.01, "90th_percentile": 44.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 83.13, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 83.13, "10th_percentile": 83.13, "90th_percentile": 83.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 47.24, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.24, "10th_percentile": 47.24, "90th_percentile": 47.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 63.72, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 63.72, "10th_percentile": 63.72, "90th_percentile": 63.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 78.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 78.24, "10th_percentile": 78.24, "90th_percentile": 78.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 53.15, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 53.15, "10th_percentile": 53.15, "90th_percentile": 53.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 73.35, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 73.35, "10th_percentile": 73.35, "90th_percentile": 73.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 97.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 97.8, "10th_percentile": 97.8, "90th_percentile": 97.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 65.43, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.43, "10th_percentile": 65.43, "90th_percentile": 65.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 49.1, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.1, "10th_percentile": 49.1, "90th_percentile": 49.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 24.84, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 24.84, "10th_percentile": 24.84, "90th_percentile": 24.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 67.78, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.78, "10th_percentile": 67.78, "90th_percentile": 67.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 34.03, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 34.03, "10th_percentile": 34.03, "90th_percentile": 34.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 63.96, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.96, "10th_percentile": 63.96, "90th_percentile": 63.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 97.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 97.8, "10th_percentile": 97.8, "90th_percentile": 97.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 97.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 97.8, "10th_percentile": 97.8, "90th_percentile": 97.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 18.58, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 18.58, "10th_percentile": 18.58, "90th_percentile": 18.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 18.58, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 18.58, "10th_percentile": 18.58, "90th_percentile": 18.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 54.67, "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": 54.67, "10th_percentile": 54.67, "90th_percentile": 54.67, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 55.11, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.11, "10th_percentile": 55.11, "90th_percentile": 55.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 65.58, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.58, "10th_percentile": 65.58, "90th_percentile": 65.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 79.71, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.71, "10th_percentile": 79.71, "90th_percentile": 79.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 61.72, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.72, "10th_percentile": 61.72, "90th_percentile": 61.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 63.72, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 63.72, "10th_percentile": 63.72, "90th_percentile": 63.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "DRILL BIT CANN FLEX 16MM 03.037.002", "code_information": [ { "code": "SUP-317080", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 900.54, "maximum": 4739.7, "setting": "outpatient", "gross_charge": 4739.7, "discounted_cash": 3317.79, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4739.7, "10th_percentile": 4739.7, "90th_percentile": 4739.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4739.7, "10th_percentile": 4739.7, "90th_percentile": 4739.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4739.7, "10th_percentile": 4739.7, "90th_percentile": 4739.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4739.7, "10th_percentile": 4739.7, "90th_percentile": 4739.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4739.7, "10th_percentile": 4739.7, "90th_percentile": 4739.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4739.7, "10th_percentile": 4739.7, "90th_percentile": 4739.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 900.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 900.54, "10th_percentile": 900.54, "90th_percentile": 900.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4147.24, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4147.24, "10th_percentile": 4147.24, "90th_percentile": 4147.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3194.56, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3194.56, "10th_percentile": 3194.56, "90th_percentile": 3194.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3862.86, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3862.86, "10th_percentile": 3862.86, "90th_percentile": 3862.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2147.08, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2147.08, "10th_percentile": 2147.08, "90th_percentile": 2147.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2132.87, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2132.87, "10th_percentile": 2132.87, "90th_percentile": 2132.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 4028.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4028.75, "10th_percentile": 4028.75, "90th_percentile": 4028.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2289.28, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2289.28, "10th_percentile": 2289.28, "90th_percentile": 2289.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3087.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3087.91, "10th_percentile": 3087.91, "90th_percentile": 3087.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 3791.76, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 3791.76, "10th_percentile": 3791.76, "90th_percentile": 3791.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2576.03, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2576.03, "10th_percentile": 2576.03, "90th_percentile": 2576.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3554.78, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 3554.78, "10th_percentile": 3554.78, "90th_percentile": 3554.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4739.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4739.7, "10th_percentile": 4739.7, "90th_percentile": 4739.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3170.86, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3170.86, "10th_percentile": 3170.86, "90th_percentile": 3170.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2379.33, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2379.33, "10th_percentile": 2379.33, "90th_percentile": 2379.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1203.88, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1203.88, "10th_percentile": 1203.88, "90th_percentile": 1203.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3284.61, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3284.61, "10th_percentile": 3284.61, "90th_percentile": 3284.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1649.42, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1649.42, "10th_percentile": 1649.42, "90th_percentile": 1649.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3099.76, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3099.76, "10th_percentile": 3099.76, "90th_percentile": 3099.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4739.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4739.7, "10th_percentile": 4739.7, "90th_percentile": 4739.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4739.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4739.7, "10th_percentile": 4739.7, "90th_percentile": 4739.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 900.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 900.54, "10th_percentile": 900.54, "90th_percentile": 900.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 900.54, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 900.54, "10th_percentile": 900.54, "90th_percentile": 900.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2649.49, "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": 2649.49, "10th_percentile": 2649.49, "90th_percentile": 2649.49, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2670.82, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2670.82, "10th_percentile": 2670.82, "90th_percentile": 2670.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3178.44, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3178.44, "10th_percentile": 3178.44, "90th_percentile": 3178.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3862.86, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3862.86, "10th_percentile": 3862.86, "90th_percentile": 3862.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2991.22, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2991.22, "10th_percentile": 2991.22, "90th_percentile": 2991.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3087.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3087.91, "10th_percentile": 3087.91, "90th_percentile": 3087.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "DRILL BIT SLD 1.7MM", "code_information": [ { "code": "SUP-148225", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 125.5, "maximum": 660.55, "setting": "outpatient", "gross_charge": 660.55, "discounted_cash": 462.38, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 660.55, "10th_percentile": 660.55, "90th_percentile": 660.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 660.55, "10th_percentile": 660.55, "90th_percentile": 660.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 660.55, "10th_percentile": 660.55, "90th_percentile": 660.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 660.55, "10th_percentile": 660.55, "90th_percentile": 660.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 660.55, "10th_percentile": 660.55, "90th_percentile": 660.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 660.55, "10th_percentile": 660.55, "90th_percentile": 660.55, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 125.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 125.5, "10th_percentile": 125.5, "90th_percentile": 125.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 577.98, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 577.98, "10th_percentile": 577.98, "90th_percentile": 577.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 445.21, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 445.21, "10th_percentile": 445.21, "90th_percentile": 445.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 538.35, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 538.35, "10th_percentile": 538.35, "90th_percentile": 538.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 299.23, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 299.23, "10th_percentile": 299.23, "90th_percentile": 299.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 297.25, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 297.25, "10th_percentile": 297.25, "90th_percentile": 297.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 561.47, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 561.47, "10th_percentile": 561.47, "90th_percentile": 561.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 319.05, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 319.05, "10th_percentile": 319.05, "90th_percentile": 319.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 430.35, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 430.35, "10th_percentile": 430.35, "90th_percentile": 430.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 528.44, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 528.44, "10th_percentile": 528.44, "90th_percentile": 528.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 359.01, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 359.01, "10th_percentile": 359.01, "90th_percentile": 359.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 495.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 495.41, "10th_percentile": 495.41, "90th_percentile": 495.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 660.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 660.55, "10th_percentile": 660.55, "90th_percentile": 660.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 441.91, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 441.91, "10th_percentile": 441.91, "90th_percentile": 441.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 331.6, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.6, "10th_percentile": 331.6, "90th_percentile": 331.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 167.78, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 167.78, "10th_percentile": 167.78, "90th_percentile": 167.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 457.76, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 457.76, "10th_percentile": 457.76, "90th_percentile": 457.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 229.87, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 229.87, "10th_percentile": 229.87, "90th_percentile": 229.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 432.0, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.0, "10th_percentile": 432.0, "90th_percentile": 432.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 660.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 660.55, "10th_percentile": 660.55, "90th_percentile": 660.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 660.55, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 660.55, "10th_percentile": 660.55, "90th_percentile": 660.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 125.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 125.5, "10th_percentile": 125.5, "90th_percentile": 125.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 125.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 125.5, "10th_percentile": 125.5, "90th_percentile": 125.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 369.25, "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": 369.25, "10th_percentile": 369.25, "90th_percentile": 369.25, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 372.22, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 372.22, "10th_percentile": 372.22, "90th_percentile": 372.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 442.96, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.96, "10th_percentile": 442.96, "90th_percentile": 442.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 538.35, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 538.35, "10th_percentile": 538.35, "90th_percentile": 538.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 416.87, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 416.87, "10th_percentile": 416.87, "90th_percentile": 416.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 430.35, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 430.35, "10th_percentile": 430.35, "90th_percentile": 430.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "DRILL BIT SYNTHES 3.2MM (310.32)", "code_information": [ { "code": "SUP-8003437", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 108.62, "maximum": 571.7, "setting": "outpatient", "gross_charge": 571.7, "discounted_cash": 400.19, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 571.7, "10th_percentile": 571.7, "90th_percentile": 571.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 571.7, "10th_percentile": 571.7, "90th_percentile": 571.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 571.7, "10th_percentile": 571.7, "90th_percentile": 571.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 571.7, "10th_percentile": 571.7, "90th_percentile": 571.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 571.7, "10th_percentile": 571.7, "90th_percentile": 571.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 571.7, "10th_percentile": 571.7, "90th_percentile": 571.7, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 108.62, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 108.62, "10th_percentile": 108.62, "90th_percentile": 108.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 500.24, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 500.24, "10th_percentile": 500.24, "90th_percentile": 500.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 385.33, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 385.33, "10th_percentile": 385.33, "90th_percentile": 385.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 465.94, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 465.94, "10th_percentile": 465.94, "90th_percentile": 465.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 258.98, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.98, "10th_percentile": 258.98, "90th_percentile": 258.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 257.27, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 257.27, "10th_percentile": 257.27, "90th_percentile": 257.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 485.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 485.95, "10th_percentile": 485.95, "90th_percentile": 485.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 276.13, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 276.13, "10th_percentile": 276.13, "90th_percentile": 276.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 372.46, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 372.46, "10th_percentile": 372.46, "90th_percentile": 372.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 457.36, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 457.36, "10th_percentile": 457.36, "90th_percentile": 457.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 310.72, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 310.72, "10th_percentile": 310.72, "90th_percentile": 310.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 428.78, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 428.78, "10th_percentile": 428.78, "90th_percentile": 428.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 571.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 571.7, "10th_percentile": 571.7, "90th_percentile": 571.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 382.47, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 382.47, "10th_percentile": 382.47, "90th_percentile": 382.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 286.99, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 286.99, "10th_percentile": 286.99, "90th_percentile": 286.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 145.21, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 145.21, "10th_percentile": 145.21, "90th_percentile": 145.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 396.19, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 396.19, "10th_percentile": 396.19, "90th_percentile": 396.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 198.95, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 198.95, "10th_percentile": 198.95, "90th_percentile": 198.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 373.89, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 373.89, "10th_percentile": 373.89, "90th_percentile": 373.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 571.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 571.7, "10th_percentile": 571.7, "90th_percentile": 571.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 571.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 571.7, "10th_percentile": 571.7, "90th_percentile": 571.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 108.62, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 108.62, "10th_percentile": 108.62, "90th_percentile": 108.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 108.62, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 108.62, "10th_percentile": 108.62, "90th_percentile": 108.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 319.58, "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": 319.58, "10th_percentile": 319.58, "90th_percentile": 319.58, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 322.15, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 322.15, "10th_percentile": 322.15, "90th_percentile": 322.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 383.38, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 383.38, "10th_percentile": 383.38, "90th_percentile": 383.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 465.94, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 465.94, "10th_percentile": 465.94, "90th_percentile": 465.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 360.8, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.8, "10th_percentile": 360.8, "90th_percentile": 360.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 372.46, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 372.46, "10th_percentile": 372.46, "90th_percentile": 372.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "Defib Pads Gel 9 inch x 6 inch", "code_information": [ { "code": "SUP-952", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 4.99, "maximum": 26.27, "setting": "outpatient", "gross_charge": 26.27, "discounted_cash": 18.39, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 4.99, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 4.99, "10th_percentile": 4.99, "90th_percentile": 4.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 22.99, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 22.99, "10th_percentile": 22.99, "90th_percentile": 22.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 17.71, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 17.71, "10th_percentile": 17.71, "90th_percentile": 17.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 21.41, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.41, "10th_percentile": 21.41, "90th_percentile": 21.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 11.9, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.9, "10th_percentile": 11.9, "90th_percentile": 11.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 11.82, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 11.82, "10th_percentile": 11.82, "90th_percentile": 11.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 22.33, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 22.33, "10th_percentile": 22.33, "90th_percentile": 22.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 12.69, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.69, "10th_percentile": 12.69, "90th_percentile": 12.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 17.11, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 17.11, "10th_percentile": 17.11, "90th_percentile": 17.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 21.02, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 21.02, "10th_percentile": 21.02, "90th_percentile": 21.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 14.28, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 14.28, "10th_percentile": 14.28, "90th_percentile": 14.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 19.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 19.7, "10th_percentile": 19.7, "90th_percentile": 19.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 26.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 17.57, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.57, "10th_percentile": 17.57, "90th_percentile": 17.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 13.19, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.19, "10th_percentile": 13.19, "90th_percentile": 13.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 6.67, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 6.67, "10th_percentile": 6.67, "90th_percentile": 6.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 18.21, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.21, "10th_percentile": 18.21, "90th_percentile": 18.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 9.14, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 9.14, "10th_percentile": 9.14, "90th_percentile": 9.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 17.18, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.18, "10th_percentile": 17.18, "90th_percentile": 17.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 26.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 26.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 26.27, "10th_percentile": 26.27, "90th_percentile": 26.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 4.99, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 4.99, "10th_percentile": 4.99, "90th_percentile": 4.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 4.99, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 4.99, "10th_percentile": 4.99, "90th_percentile": 4.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 14.68, "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": 14.68, "10th_percentile": 14.68, "90th_percentile": 14.68, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14.8, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.8, "10th_percentile": 14.8, "90th_percentile": 14.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 17.62, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 21.41, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.41, "10th_percentile": 21.41, "90th_percentile": 21.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 16.58, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.58, "10th_percentile": 16.58, "90th_percentile": 16.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 17.11, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 17.11, "10th_percentile": 17.11, "90th_percentile": 17.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "ECULIZUMAB-AAGH 300 MG/30 ML IV SOLN", "drug_information": { "unit": 30.0, "type": "ML" }, "code_information": [ { "code": "RX-246304", "type": "CDM" }, { "code": "Q5151", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "51759-0208-13", "type": "NDC" } ], "standard_charges": [ { "minimum": 2520.93, "maximum": 36535.25, "setting": "outpatient", "gross_charge": 36535.25, "discounted_cash": 25574.67, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 6941.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 6941.7, "10th_percentile": 6941.7, "90th_percentile": 6941.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 6941.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 6941.7, "10th_percentile": 6941.7, "90th_percentile": 6941.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 6941.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 6941.7, "10th_percentile": 6941.7, "90th_percentile": 6941.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 23017.21, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23017.21, "10th_percentile": 23017.21, "90th_percentile": 23017.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 29849.3, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29849.3, "10th_percentile": 29849.3, "90th_percentile": 29849.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20423.2, "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": 20423.2, "10th_percentile": 20423.2, "90th_percentile": 20423.2, "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": "VWH BCBS HMO", "standard_charge_dollar": 23802.72, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 23802.72, "10th_percentile": 23802.72, "90th_percentile": 23802.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 22067.29, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22067.29, "10th_percentile": 22067.29, "90th_percentile": 22067.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 22067.29, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22067.29, "10th_percentile": 22067.29, "90th_percentile": 22067.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 36535.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 36535.25, "10th_percentile": 36535.25, "90th_percentile": 36535.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 36535.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 36535.25, "10th_percentile": 36535.25, "90th_percentile": 36535.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 31054.96, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 31054.96, "10th_percentile": 31054.96, "90th_percentile": 31054.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 31968.34, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 31968.34, "10th_percentile": 31968.34, "90th_percentile": 31968.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 9279.95, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 9279.95, "10th_percentile": 9279.95, "90th_percentile": 9279.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 36535.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 36535.25, "10th_percentile": 36535.25, "90th_percentile": 36535.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 16440.86, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 16440.86, "10th_percentile": 16440.86, "90th_percentile": 16440.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 29228.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 29228.2, "10th_percentile": 29228.2, "90th_percentile": 29228.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 23802.72, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 23802.72, "10th_percentile": 23802.72, "90th_percentile": 23802.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 19856.91, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 19856.91, "10th_percentile": 19856.91, "90th_percentile": 19856.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 24624.76, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 24624.76, "10th_percentile": 24624.76, "90th_percentile": 24624.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 27401.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 27401.44, "10th_percentile": 27401.44, "90th_percentile": 27401.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 29849.3, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29849.3, "10th_percentile": 29849.3, "90th_percentile": 29849.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 12714.27, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 12714.27, "10th_percentile": 12714.27, "90th_percentile": 12714.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 25318.93, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25318.93, "10th_percentile": 25318.93, "90th_percentile": 25318.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 23894.05, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23894.05, "10th_percentile": 23894.05, "90th_percentile": 23894.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2520.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2520.93, "10th_percentile": 2520.93, "90th_percentile": 2520.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2520.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2520.93, "10th_percentile": 2520.93, "90th_percentile": 2520.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2520.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2520.93, "10th_percentile": 2520.93, "90th_percentile": 2520.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2520.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2520.93, "10th_percentile": 2520.93, "90th_percentile": 2520.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2520.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2520.93, "10th_percentile": 2520.93, "90th_percentile": 2520.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2520.93, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2520.93, "10th_percentile": 2520.93, "90th_percentile": 2520.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "ENDO SPECIMEN POUCH ENDOCATCH COVIDIEN 15MM 5IN X 9IN (173049)", "code_information": [ { "code": "SUP-9044211", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 172.03, "maximum": 905.41, "setting": "outpatient", "gross_charge": 905.41, "discounted_cash": 633.79, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.41, "10th_percentile": 905.41, "90th_percentile": 905.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.41, "10th_percentile": 905.41, "90th_percentile": 905.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.41, "10th_percentile": 905.41, "90th_percentile": 905.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.41, "10th_percentile": 905.41, "90th_percentile": 905.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.41, "10th_percentile": 905.41, "90th_percentile": 905.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.41, "10th_percentile": 905.41, "90th_percentile": 905.41, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 172.03, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 172.03, "10th_percentile": 172.03, "90th_percentile": 172.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 792.23, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 792.23, "10th_percentile": 792.23, "90th_percentile": 792.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 610.25, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 610.25, "10th_percentile": 610.25, "90th_percentile": 610.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 737.91, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 737.91, "10th_percentile": 737.91, "90th_percentile": 737.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 410.15, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 410.15, "10th_percentile": 410.15, "90th_percentile": 410.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 407.43, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 407.43, "10th_percentile": 407.43, "90th_percentile": 407.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 769.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 769.6, "10th_percentile": 769.6, "90th_percentile": 769.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 437.31, "10th_percentile": 437.31, "90th_percentile": 437.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 589.87, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 589.87, "10th_percentile": 589.87, "90th_percentile": 589.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 724.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 724.33, "10th_percentile": 724.33, "90th_percentile": 724.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 492.09, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 492.09, "10th_percentile": 492.09, "90th_percentile": 492.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 679.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 679.06, "10th_percentile": 679.06, "90th_percentile": 679.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 905.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 905.41, "10th_percentile": 905.41, "90th_percentile": 905.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 605.72, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 605.72, "10th_percentile": 605.72, "90th_percentile": 605.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 454.52, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 454.52, "10th_percentile": 454.52, "90th_percentile": 454.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 229.97, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 229.97, "10th_percentile": 229.97, "90th_percentile": 229.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 627.45, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 627.45, "10th_percentile": 627.45, "90th_percentile": 627.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 315.08, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 315.08, "10th_percentile": 315.08, "90th_percentile": 315.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 592.14, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 592.14, "10th_percentile": 592.14, "90th_percentile": 592.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 905.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 905.41, "10th_percentile": 905.41, "90th_percentile": 905.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 905.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 905.41, "10th_percentile": 905.41, "90th_percentile": 905.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 172.03, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 172.03, "10th_percentile": 172.03, "90th_percentile": 172.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 172.03, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 172.03, "10th_percentile": 172.03, "90th_percentile": 172.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 506.12, "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": 506.12, "10th_percentile": 506.12, "90th_percentile": 506.12, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 510.2, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 510.2, "10th_percentile": 510.2, "90th_percentile": 510.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 607.17, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 607.17, "10th_percentile": 607.17, "90th_percentile": 607.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 737.91, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 737.91, "10th_percentile": 737.91, "90th_percentile": 737.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 571.4, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 571.4, "10th_percentile": 571.4, "90th_percentile": 571.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 589.87, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 589.87, "10th_percentile": 589.87, "90th_percentile": 589.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "ENOXAPARIN 40 MG SUBQ SYRG", "drug_information": { "unit": 0.4, "type": "ML" }, "code_information": [ { "code": "RX-90211", "type": "CDM" }, { "code": "J1650", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00075-0620-40", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.8, "maximum": 142.0, "setting": "outpatient", "gross_charge": 142.0, "discounted_cash": 99.4, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 26.98, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 26.98, "10th_percentile": 26.98, "90th_percentile": 26.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 26.98, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 26.98, "10th_percentile": 26.98, "90th_percentile": 26.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 26.98, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 26.98, "10th_percentile": 26.98, "90th_percentile": 26.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 89.46, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.46, "10th_percentile": 89.46, "90th_percentile": 89.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 116.01, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.01, "10th_percentile": 116.01, "90th_percentile": 116.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 79.38, "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": 79.38, "10th_percentile": 79.38, "90th_percentile": 79.38, "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": "VWH BCBS HMO", "standard_charge_dollar": 92.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 92.51, "10th_percentile": 92.51, "90th_percentile": 92.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 85.77, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.77, "10th_percentile": 85.77, "90th_percentile": 85.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 85.77, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.77, "10th_percentile": 85.77, "90th_percentile": 85.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 142.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 142.0, "10th_percentile": 142.0, "90th_percentile": 142.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 142.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 142.0, "10th_percentile": 142.0, "90th_percentile": 142.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 120.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 120.7, "10th_percentile": 120.7, "90th_percentile": 120.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 124.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% 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 Services; 87.5% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 142.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 142.0, "10th_percentile": 142.0, "90th_percentile": 142.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 63.9, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 63.9, "10th_percentile": 63.9, "90th_percentile": 63.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 113.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 113.6, "10th_percentile": 113.6, "90th_percentile": 113.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 92.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 92.51, "10th_percentile": 92.51, "90th_percentile": 92.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 77.18, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 77.18, "10th_percentile": 77.18, "90th_percentile": 77.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 95.71, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 95.71, "10th_percentile": 95.71, "90th_percentile": 95.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 106.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 106.5, "10th_percentile": 106.5, "90th_percentile": 106.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 116.01, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.01, "10th_percentile": 116.01, "90th_percentile": 116.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 49.42, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 49.42, "10th_percentile": 49.42, "90th_percentile": 49.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "ENOXAPARIN 40 MG SUBQ SYRG", "drug_information": { "unit": 0.4, "type": "ML" }, "code_information": [ { "code": "RX-90211", "type": "CDM" }, { "code": "J1650", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00955-1004-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.8, "maximum": 142.0, "setting": "outpatient", "gross_charge": 142.0, "discounted_cash": 99.4, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 26.98, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 26.98, "10th_percentile": 26.98, "90th_percentile": 26.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 26.98, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 26.98, "10th_percentile": 26.98, "90th_percentile": 26.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 26.98, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 26.98, "10th_percentile": 26.98, "90th_percentile": 26.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 89.46, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.46, "10th_percentile": 89.46, "90th_percentile": 89.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 116.01, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.01, "10th_percentile": 116.01, "90th_percentile": 116.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 79.38, "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": 79.38, "10th_percentile": 79.38, "90th_percentile": 79.38, "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": "VWH BCBS HMO", "standard_charge_dollar": 92.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 92.51, "10th_percentile": 92.51, "90th_percentile": 92.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 85.77, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.77, "10th_percentile": 85.77, "90th_percentile": 85.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 85.77, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.77, "10th_percentile": 85.77, "90th_percentile": 85.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 142.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 142.0, "10th_percentile": 142.0, "90th_percentile": 142.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 142.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 142.0, "10th_percentile": 142.0, "90th_percentile": 142.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 120.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 120.7, "10th_percentile": 120.7, "90th_percentile": 120.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 124.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% 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 Services; 87.5% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 142.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 142.0, "10th_percentile": 142.0, "90th_percentile": 142.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 63.9, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 63.9, "10th_percentile": 63.9, "90th_percentile": 63.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 113.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 113.6, "10th_percentile": 113.6, "90th_percentile": 113.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 92.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 92.51, "10th_percentile": 92.51, "90th_percentile": 92.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 77.18, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 77.18, "10th_percentile": 77.18, "90th_percentile": 77.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 95.71, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 95.71, "10th_percentile": 95.71, "90th_percentile": 95.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 106.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 106.5, "10th_percentile": 106.5, "90th_percentile": 106.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 116.01, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.01, "10th_percentile": 116.01, "90th_percentile": 116.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 49.42, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 49.42, "10th_percentile": 49.42, "90th_percentile": 49.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 9.8, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "ENOXAPARIN 150 MG SUBQ SYRG", "drug_information": { "unit": 1.0, "type": "ML" }, "code_information": [ { "code": "RX-87303", "type": "CDM" }, { "code": "J1650", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00075-8025-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.18, "maximum": 191.0, "setting": "outpatient", "gross_charge": 191.0, "discounted_cash": 133.7, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 66.47, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 66.47, "10th_percentile": 66.47, "90th_percentile": 66.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 143.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 143.25, "10th_percentile": 143.25, "90th_percentile": 143.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 162.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 162.35, "10th_percentile": 162.35, "90th_percentile": 162.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 85.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 85.95, "10th_percentile": 85.95, "90th_percentile": 85.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 103.81, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 103.81, "10th_percentile": 103.81, "90th_percentile": 103.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 128.73, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 128.73, "10th_percentile": 128.73, "90th_percentile": 128.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 167.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 167.13, "10th_percentile": 167.13, "90th_percentile": 167.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 124.44, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 124.44, "10th_percentile": 124.44, "90th_percentile": 124.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 152.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 152.8, "10th_percentile": 152.8, "90th_percentile": 152.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 191.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 191.0, "10th_percentile": 191.0, "90th_percentile": 191.0, "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": "VWH BCBS PPO", "standard_charge_dollar": 156.05, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.05, "10th_percentile": 156.05, "90th_percentile": 156.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 191.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 191.0, "10th_percentile": 191.0, "90th_percentile": 191.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 191.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 191.0, "10th_percentile": 191.0, "90th_percentile": 191.0, "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": "VWH BCBS PPO", "standard_charge_dollar": 156.05, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.05, "10th_percentile": 156.05, "90th_percentile": 156.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 120.33, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.33, "10th_percentile": 120.33, "90th_percentile": 120.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 106.77, "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": 106.77, "10th_percentile": 106.77, "90th_percentile": 106.77, "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": "VWH BCBS HMO", "standard_charge_dollar": 124.44, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 124.44, "10th_percentile": 124.44, "90th_percentile": 124.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 115.36, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 115.36, "10th_percentile": 115.36, "90th_percentile": 115.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 115.36, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 115.36, "10th_percentile": 115.36, "90th_percentile": 115.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 36.29, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 36.29, "10th_percentile": 36.29, "90th_percentile": 36.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 36.29, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 36.29, "10th_percentile": 36.29, "90th_percentile": 36.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 36.29, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 36.29, "10th_percentile": 36.29, "90th_percentile": 36.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.18, "10th_percentile": 13.18, "90th_percentile": 13.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.18, "10th_percentile": 13.18, "90th_percentile": 13.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.18, "10th_percentile": 13.18, "90th_percentile": 13.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.18, "10th_percentile": 13.18, "90th_percentile": 13.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.18, "10th_percentile": 13.18, "90th_percentile": 13.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.18, "10th_percentile": 13.18, "90th_percentile": 13.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "EPINEPHRINE 1 MG/ML INJ SOLN", "drug_information": { "unit": 30.0, "type": "ML" }, "code_information": [ { "code": "RX-2850", "type": "CDM" }, { "code": "J0165", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "76329-9060-00", "type": "NDC" } ], "standard_charges": [ { "minimum": 76.19, "maximum": 1104.25, "setting": "outpatient", "gross_charge": 1104.25, "discounted_cash": 772.97, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 209.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 209.81, "10th_percentile": 209.81, "90th_percentile": 209.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 209.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 209.81, "10th_percentile": 209.81, "90th_percentile": 209.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 209.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 209.81, "10th_percentile": 209.81, "90th_percentile": 209.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 695.68, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 695.68, "10th_percentile": 695.68, "90th_percentile": 695.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 902.17, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 902.17, "10th_percentile": 902.17, "90th_percentile": 902.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 617.28, "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": 617.28, "10th_percentile": 617.28, "90th_percentile": 617.28, "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": "VWH BCBS HMO", "standard_charge_dollar": 719.42, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 719.42, "10th_percentile": 719.42, "90th_percentile": 719.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 666.97, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 666.97, "10th_percentile": 666.97, "90th_percentile": 666.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 666.97, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 666.97, "10th_percentile": 666.97, "90th_percentile": 666.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1104.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1104.25, "10th_percentile": 1104.25, "90th_percentile": 1104.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1104.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1104.25, "10th_percentile": 1104.25, "90th_percentile": 1104.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 938.61, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 938.61, "10th_percentile": 938.61, "90th_percentile": 938.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 966.22, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 966.22, "10th_percentile": 966.22, "90th_percentile": 966.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 280.48, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 280.48, "10th_percentile": 280.48, "90th_percentile": 280.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1104.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1104.25, "10th_percentile": 1104.25, "90th_percentile": 1104.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 496.91, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 496.91, "10th_percentile": 496.91, "90th_percentile": 496.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 883.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 883.4, "10th_percentile": 883.4, "90th_percentile": 883.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 719.42, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 719.42, "10th_percentile": 719.42, "90th_percentile": 719.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 600.16, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 600.16, "10th_percentile": 600.16, "90th_percentile": 600.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 744.26, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 744.26, "10th_percentile": 744.26, "90th_percentile": 744.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 828.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 828.19, "10th_percentile": 828.19, "90th_percentile": 828.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 902.17, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 902.17, "10th_percentile": 902.17, "90th_percentile": 902.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 384.28, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 384.28, "10th_percentile": 384.28, "90th_percentile": 384.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 76.19, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 76.19, "10th_percentile": 76.19, "90th_percentile": 76.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 76.19, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 76.19, "10th_percentile": 76.19, "90th_percentile": 76.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 76.19, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 76.19, "10th_percentile": 76.19, "90th_percentile": 76.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 76.19, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 76.19, "10th_percentile": 76.19, "90th_percentile": 76.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 76.19, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 76.19, "10th_percentile": 76.19, "90th_percentile": 76.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 76.19, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 76.19, "10th_percentile": 76.19, "90th_percentile": 76.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "ETOMIDATE 2 MG/ML IV SOLN", "drug_information": { "unit": 20.0, "type": "ML" }, "code_information": [ { "code": "RX-20472", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "70860-0652-20", "type": "NDC" } ], "standard_charges": [ { "minimum": 75.91, "maximum": 399.5, "setting": "outpatient", "gross_charge": 399.5, "discounted_cash": 279.65, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 399.5, "10th_percentile": 399.5, "90th_percentile": 399.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 399.5, "10th_percentile": 399.5, "90th_percentile": 399.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 399.5, "10th_percentile": 399.5, "90th_percentile": 399.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 399.5, "10th_percentile": 399.5, "90th_percentile": 399.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 399.5, "10th_percentile": 399.5, "90th_percentile": 399.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 399.5, "10th_percentile": 399.5, "90th_percentile": 399.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 325.59, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 325.59, "10th_percentile": 325.59, "90th_percentile": 325.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 223.32, "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": 223.32, "10th_percentile": 223.32, "90th_percentile": 223.32, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 267.9, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 267.9, "10th_percentile": 267.9, "90th_percentile": 267.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 252.12, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.12, "10th_percentile": 252.12, "90th_percentile": 252.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 225.12, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.12, "10th_percentile": 225.12, "90th_percentile": 225.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 260.27, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 260.27, "10th_percentile": 260.27, "90th_percentile": 260.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 399.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 399.5, "10th_percentile": 399.5, "90th_percentile": 399.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 399.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 399.5, "10th_percentile": 399.5, "90th_percentile": 399.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 75.91, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 75.91, "10th_percentile": 75.91, "90th_percentile": 75.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 75.91, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 75.91, "10th_percentile": 75.91, "90th_percentile": 75.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 101.47, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 101.47, "10th_percentile": 101.47, "90th_percentile": 101.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 139.03, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 139.03, "10th_percentile": 139.03, "90th_percentile": 139.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 276.85, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 276.85, "10th_percentile": 276.85, "90th_percentile": 276.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 261.27, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 261.27, "10th_percentile": 261.27, "90th_percentile": 261.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 399.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 399.5, "10th_percentile": 399.5, "90th_percentile": 399.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 200.55, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 200.55, "10th_percentile": 200.55, "90th_percentile": 200.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 267.27, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 267.27, "10th_percentile": 267.27, "90th_percentile": 267.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 269.26, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 269.26, "10th_percentile": 269.26, "90th_percentile": 269.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 339.58, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 339.58, "10th_percentile": 339.58, "90th_percentile": 339.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 319.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 319.6, "10th_percentile": 319.6, "90th_percentile": 319.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 260.27, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 260.27, "10th_percentile": 260.27, "90th_percentile": 260.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 179.78, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 179.78, "10th_percentile": 179.78, "90th_percentile": 179.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 192.96, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.96, "10th_percentile": 192.96, "90th_percentile": 192.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 325.59, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 325.59, "10th_percentile": 325.59, "90th_percentile": 325.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 299.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 299.63, "10th_percentile": 299.63, "90th_percentile": 299.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 180.97, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 180.97, "10th_percentile": 180.97, "90th_percentile": 180.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 349.56, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 349.56, "10th_percentile": 349.56, "90th_percentile": 349.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 217.13, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 217.13, "10th_percentile": 217.13, "90th_percentile": 217.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 75.91, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 75.91, "10th_percentile": 75.91, "90th_percentile": 75.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "EVACUATOR UROVAC BLADDER M0067301250", "code_information": [ { "code": "SUP-9046762", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 48.26, "maximum": 254.01, "setting": "outpatient", "gross_charge": 254.01, "discounted_cash": 177.81, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 48.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 48.26, "10th_percentile": 48.26, "90th_percentile": 48.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 222.26, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 222.26, "10th_percentile": 222.26, "90th_percentile": 222.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 171.2, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 171.2, "10th_percentile": 171.2, "90th_percentile": 171.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 207.02, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.02, "10th_percentile": 207.02, "90th_percentile": 207.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 115.07, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 115.07, "10th_percentile": 115.07, "90th_percentile": 115.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 114.3, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 114.3, "10th_percentile": 114.3, "90th_percentile": 114.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 215.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 215.91, "10th_percentile": 215.91, "90th_percentile": 215.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 122.69, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.69, "10th_percentile": 122.69, "90th_percentile": 122.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 165.49, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 165.49, "10th_percentile": 165.49, "90th_percentile": 165.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 203.21, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 203.21, "10th_percentile": 203.21, "90th_percentile": 203.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 138.05, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 138.05, "10th_percentile": 138.05, "90th_percentile": 138.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 190.51, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 190.51, "10th_percentile": 190.51, "90th_percentile": 190.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 254.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 169.93, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.93, "10th_percentile": 169.93, "90th_percentile": 169.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 127.51, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 127.51, "10th_percentile": 127.51, "90th_percentile": 127.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 64.52, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 64.52, "10th_percentile": 64.52, "90th_percentile": 64.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 176.03, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.03, "10th_percentile": 176.03, "90th_percentile": 176.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 88.4, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 88.4, "10th_percentile": 88.4, "90th_percentile": 88.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 166.12, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 166.12, "10th_percentile": 166.12, "90th_percentile": 166.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 254.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 254.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 48.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 48.26, "10th_percentile": 48.26, "90th_percentile": 48.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 48.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 48.26, "10th_percentile": 48.26, "90th_percentile": 48.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 141.99, "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": 141.99, "10th_percentile": 141.99, "90th_percentile": 141.99, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 143.13, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 143.13, "10th_percentile": 143.13, "90th_percentile": 143.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 170.34, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 170.34, "10th_percentile": 170.34, "90th_percentile": 170.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 207.02, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.02, "10th_percentile": 207.02, "90th_percentile": 207.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 160.31, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.31, "10th_percentile": 160.31, "90th_percentile": 160.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 165.49, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 165.49, "10th_percentile": 165.49, "90th_percentile": 165.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "FAMOTIDINE (PF) 20 MG/2 ML IV SOLN", "drug_information": { "unit": 2.0, "type": "ML" }, "code_information": [ { "code": "RX-102681", "type": "CDM" }, { "code": "J1308", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "63323-0739-16", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.52, "maximum": 36.5, "setting": "outpatient", "gross_charge": 36.5, "discounted_cash": 25.55, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 6.94, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 6.94, "10th_percentile": 6.94, "90th_percentile": 6.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 6.94, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 6.94, "10th_percentile": 6.94, "90th_percentile": 6.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 6.94, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 6.94, "10th_percentile": 6.94, "90th_percentile": 6.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 23.0, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.0, "10th_percentile": 23.0, "90th_percentile": 23.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 29.82, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.82, "10th_percentile": 29.82, "90th_percentile": 29.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20.4, "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": 20.4, "10th_percentile": 20.4, "90th_percentile": 20.4, "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": "VWH BCBS HMO", "standard_charge_dollar": 23.78, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 23.78, "10th_percentile": 23.78, "90th_percentile": 23.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 22.05, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.05, "10th_percentile": 22.05, "90th_percentile": 22.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 22.05, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.05, "10th_percentile": 22.05, "90th_percentile": 22.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 36.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 36.5, "10th_percentile": 36.5, "90th_percentile": 36.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 36.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 36.5, "10th_percentile": 36.5, "90th_percentile": 36.5, "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": "VWH HFN", "standard_charge_dollar": 31.03, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 31.03, "10th_percentile": 31.03, "90th_percentile": 31.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 31.94, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 31.94, "10th_percentile": 31.94, "90th_percentile": 31.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 9.27, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 9.27, "10th_percentile": 9.27, "90th_percentile": 9.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 36.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 36.5, "10th_percentile": 36.5, "90th_percentile": 36.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 16.43, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 16.43, "10th_percentile": 16.43, "90th_percentile": 16.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 29.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 29.2, "10th_percentile": 29.2, "90th_percentile": 29.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 23.78, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 23.78, "10th_percentile": 23.78, "90th_percentile": 23.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 19.84, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 19.84, "10th_percentile": 19.84, "90th_percentile": 19.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 24.6, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 24.6, "10th_percentile": 24.6, "90th_percentile": 24.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 27.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 27.38, "10th_percentile": 27.38, "90th_percentile": 27.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 29.82, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.82, "10th_percentile": 29.82, "90th_percentile": 29.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 12.7, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 12.7, "10th_percentile": 12.7, "90th_percentile": 12.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 2.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_algorithm": "No contract line matched", "median_amount": 36.5, "10th_percentile": 36.5, "90th_percentile": 36.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "FAT EMULSION BOLUS FROM INFUSION (LIPID RESCUE) (ML/KG)", "drug_information": { "unit": 500.0, "type": "ML" }, "code_information": [ { "code": "RX-4000000622", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "99991-0021-39", "type": "NDC" } ], "standard_charges": [ { "minimum": 88.73, "maximum": 467.0, "setting": "outpatient", "gross_charge": 467.0, "discounted_cash": 326.9, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 467.0, "10th_percentile": 467.0, "90th_percentile": 467.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 467.0, "10th_percentile": 467.0, "90th_percentile": 467.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 467.0, "10th_percentile": 467.0, "90th_percentile": 467.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 467.0, "10th_percentile": 467.0, "90th_percentile": 467.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 467.0, "10th_percentile": 467.0, "90th_percentile": 467.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 467.0, "10th_percentile": 467.0, "90th_percentile": 467.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 380.61, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 380.61, "10th_percentile": 380.61, "90th_percentile": 380.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 261.05, "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": 261.05, "10th_percentile": 261.05, "90th_percentile": 261.05, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 313.17, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 313.17, "10th_percentile": 313.17, "90th_percentile": 313.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 294.72, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 294.72, "10th_percentile": 294.72, "90th_percentile": 294.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 263.15, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 263.15, "10th_percentile": 263.15, "90th_percentile": 263.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 304.25, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 304.25, "10th_percentile": 304.25, "90th_percentile": 304.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 467.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 467.0, "10th_percentile": 467.0, "90th_percentile": 467.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 467.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 467.0, "10th_percentile": 467.0, "90th_percentile": 467.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 88.73, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 88.73, "10th_percentile": 88.73, "90th_percentile": 88.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 88.73, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 88.73, "10th_percentile": 88.73, "90th_percentile": 88.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 118.62, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 118.62, "10th_percentile": 118.62, "90th_percentile": 118.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 162.52, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 162.52, "10th_percentile": 162.52, "90th_percentile": 162.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 323.63, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 323.63, "10th_percentile": 323.63, "90th_percentile": 323.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 305.42, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 305.42, "10th_percentile": 305.42, "90th_percentile": 305.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 467.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 467.0, "10th_percentile": 467.0, "90th_percentile": 467.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 234.43, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 234.43, "10th_percentile": 234.43, "90th_percentile": 234.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 312.42, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 312.42, "10th_percentile": 312.42, "90th_percentile": 312.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 314.76, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 314.76, "10th_percentile": 314.76, "90th_percentile": 314.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 396.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 396.95, "10th_percentile": 396.95, "90th_percentile": 396.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 373.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 373.6, "10th_percentile": 373.6, "90th_percentile": 373.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 304.25, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 304.25, "10th_percentile": 304.25, "90th_percentile": 304.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 210.15, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 210.15, "10th_percentile": 210.15, "90th_percentile": 210.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 225.56, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.56, "10th_percentile": 225.56, "90th_percentile": 225.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 380.61, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 380.61, "10th_percentile": 380.61, "90th_percentile": 380.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 350.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 350.25, "10th_percentile": 350.25, "90th_percentile": 350.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 211.55, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 211.55, "10th_percentile": 211.55, "90th_percentile": 211.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 408.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 408.63, "10th_percentile": 408.63, "90th_percentile": 408.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 253.81, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 253.81, "10th_percentile": 253.81, "90th_percentile": 253.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 88.73, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 88.73, "10th_percentile": 88.73, "90th_percentile": 88.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "FENOFIBRATE 54 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-175553", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "63304-0900-90", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2.5, "setting": "outpatient", "gross_charge": 2.5, "discounted_cash": 1.75, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1.64, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.64, "10th_percentile": 1.64, "90th_percentile": 1.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1.73, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 0.87, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 0.87, "10th_percentile": 0.87, "90th_percentile": 0.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.64, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 0.64, "10th_percentile": 0.64, "90th_percentile": 0.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.48, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.63, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2.04, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.04, "10th_percentile": 2.04, "90th_percentile": 2.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 0.48, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.68, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.58, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.58, "10th_percentile": 1.58, "90th_percentile": 1.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.41, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.63, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.4, "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": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "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": "VWH BCBS PPO", "standard_charge_dollar": 2.04, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.04, "10th_percentile": 2.04, "90th_percentile": 2.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1.69, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1.21, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.21, "10th_percentile": 1.21, "90th_percentile": 1.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 0.48, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2.13, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1.88, "10th_percentile": 1.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2.19, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2.19, "10th_percentile": 2.19, "90th_percentile": 2.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1.36, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1.26, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1.67, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.67, "10th_percentile": 1.67, "90th_percentile": 1.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "FIBER LASER FLEXIVA PULSE 550 ID-M006L8406931", "code_information": [ { "code": "SUP-414986", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 587.78, "maximum": 3093.57, "setting": "outpatient", "gross_charge": 3093.57, "discounted_cash": 2165.5, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3093.57, "10th_percentile": 3093.57, "90th_percentile": 3093.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3093.57, "10th_percentile": 3093.57, "90th_percentile": 3093.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3093.57, "10th_percentile": 3093.57, "90th_percentile": 3093.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3093.57, "10th_percentile": 3093.57, "90th_percentile": 3093.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3093.57, "10th_percentile": 3093.57, "90th_percentile": 3093.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3093.57, "10th_percentile": 3093.57, "90th_percentile": 3093.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 587.78, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 587.78, "10th_percentile": 587.78, "90th_percentile": 587.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2706.87, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2706.87, "10th_percentile": 2706.87, "90th_percentile": 2706.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2085.07, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2085.07, "10th_percentile": 2085.07, "90th_percentile": 2085.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2521.26, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2521.26, "10th_percentile": 2521.26, "90th_percentile": 2521.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1401.39, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1401.39, "10th_percentile": 1401.39, "90th_percentile": 1401.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1392.11, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1392.11, "10th_percentile": 1392.11, "90th_percentile": 1392.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2629.53, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2629.53, "10th_percentile": 2629.53, "90th_percentile": 2629.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1494.19, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1494.19, "10th_percentile": 1494.19, "90th_percentile": 1494.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2015.46, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2015.46, "10th_percentile": 2015.46, "90th_percentile": 2015.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2474.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2474.86, "10th_percentile": 2474.86, "90th_percentile": 2474.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1681.36, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1681.36, "10th_percentile": 1681.36, "90th_percentile": 1681.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2320.18, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2320.18, "10th_percentile": 2320.18, "90th_percentile": 2320.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3093.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3093.57, "10th_percentile": 3093.57, "90th_percentile": 3093.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2069.6, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2069.6, "10th_percentile": 2069.6, "90th_percentile": 2069.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1552.97, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1552.97, "10th_percentile": 1552.97, "90th_percentile": 1552.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 785.77, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 785.77, "10th_percentile": 785.77, "90th_percentile": 785.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2143.84, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2143.84, "10th_percentile": 2143.84, "90th_percentile": 2143.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1076.56, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1076.56, "10th_percentile": 1076.56, "90th_percentile": 1076.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2023.19, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2023.19, "10th_percentile": 2023.19, "90th_percentile": 2023.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3093.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3093.57, "10th_percentile": 3093.57, "90th_percentile": 3093.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3093.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3093.57, "10th_percentile": 3093.57, "90th_percentile": 3093.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 587.78, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 587.78, "10th_percentile": 587.78, "90th_percentile": 587.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 587.78, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 587.78, "10th_percentile": 587.78, "90th_percentile": 587.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1729.31, "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": 1729.31, "10th_percentile": 1729.31, "90th_percentile": 1729.31, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1743.23, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1743.23, "10th_percentile": 1743.23, "90th_percentile": 1743.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2074.55, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2074.55, "10th_percentile": 2074.55, "90th_percentile": 2074.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2521.26, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2521.26, "10th_percentile": 2521.26, "90th_percentile": 2521.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1952.35, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1952.35, "10th_percentile": 1952.35, "90th_percentile": 1952.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2015.46, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2015.46, "10th_percentile": 2015.46, "90th_percentile": 2015.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "FLEXIVA PULSE ID 242 M006L8406910", "code_information": [ { "code": "SUP-381396", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 543.45, "maximum": 2860.25, "setting": "outpatient", "gross_charge": 2860.25, "discounted_cash": 2002.17, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2860.25, "10th_percentile": 2860.25, "90th_percentile": 2860.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2860.25, "10th_percentile": 2860.25, "90th_percentile": 2860.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2860.25, "10th_percentile": 2860.25, "90th_percentile": 2860.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2860.25, "10th_percentile": 2860.25, "90th_percentile": 2860.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2860.25, "10th_percentile": 2860.25, "90th_percentile": 2860.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2860.25, "10th_percentile": 2860.25, "90th_percentile": 2860.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 543.45, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 543.45, "10th_percentile": 543.45, "90th_percentile": 543.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2502.72, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2502.72, "10th_percentile": 2502.72, "90th_percentile": 2502.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1927.81, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1927.81, "10th_percentile": 1927.81, "90th_percentile": 1927.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2331.1, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2331.1, "10th_percentile": 2331.1, "90th_percentile": 2331.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1295.69, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1295.69, "10th_percentile": 1295.69, "90th_percentile": 1295.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1287.11, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1287.11, "10th_percentile": 1287.11, "90th_percentile": 1287.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2431.21, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2431.21, "10th_percentile": 2431.21, "90th_percentile": 2431.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1381.5, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1381.5, "10th_percentile": 1381.5, "90th_percentile": 1381.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1863.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1863.45, "10th_percentile": 1863.45, "90th_percentile": 1863.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2288.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2288.2, "10th_percentile": 2288.2, "90th_percentile": 2288.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1554.55, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1554.55, "10th_percentile": 1554.55, "90th_percentile": 1554.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2145.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2145.19, "10th_percentile": 2145.19, "90th_percentile": 2145.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2860.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2860.25, "10th_percentile": 2860.25, "90th_percentile": 2860.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1913.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1913.51, "10th_percentile": 1913.51, "90th_percentile": 1913.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1435.85, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1435.85, "10th_percentile": 1435.85, "90th_percentile": 1435.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 726.5, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 726.5, "10th_percentile": 726.5, "90th_percentile": 726.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1982.15, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1982.15, "10th_percentile": 1982.15, "90th_percentile": 1982.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 995.37, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 995.37, "10th_percentile": 995.37, "90th_percentile": 995.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1870.6, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1870.6, "10th_percentile": 1870.6, "90th_percentile": 1870.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2860.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2860.25, "10th_percentile": 2860.25, "90th_percentile": 2860.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2860.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2860.25, "10th_percentile": 2860.25, "90th_percentile": 2860.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 543.45, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 543.45, "10th_percentile": 543.45, "90th_percentile": 543.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 543.45, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 543.45, "10th_percentile": 543.45, "90th_percentile": 543.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1598.88, "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": 1598.88, "10th_percentile": 1598.88, "90th_percentile": 1598.88, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1611.75, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1611.75, "10th_percentile": 1611.75, "90th_percentile": 1611.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1918.08, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1918.08, "10th_percentile": 1918.08, "90th_percentile": 1918.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2331.1, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2331.1, "10th_percentile": 2331.1, "90th_percentile": 2331.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1805.1, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1805.1, "10th_percentile": 1805.1, "90th_percentile": 1805.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1863.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1863.45, "10th_percentile": 1863.45, "90th_percentile": 1863.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "FLUOROURACIL 1 GRAM/20 ML IV SOLN", "drug_information": { "unit": 20.0, "type": "ML" }, "code_information": [ { "code": "RX-175261", "type": "CDM" }, { "code": "J9190", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "16729-0276-67", "type": "NDC" } ], "standard_charges": [ { "minimum": 77.99, "maximum": 1130.25, "setting": "outpatient", "gross_charge": 1130.25, "discounted_cash": 791.17, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 214.75, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 214.75, "10th_percentile": 214.75, "90th_percentile": 214.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 214.75, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 214.75, "10th_percentile": 214.75, "90th_percentile": 214.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 214.75, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 214.75, "10th_percentile": 214.75, "90th_percentile": 214.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 712.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 712.06, "10th_percentile": 712.06, "90th_percentile": 712.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 923.41, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 923.41, "10th_percentile": 923.41, "90th_percentile": 923.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 631.81, "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": 631.81, "10th_percentile": 631.81, "90th_percentile": 631.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 736.36, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 736.36, "10th_percentile": 736.36, "90th_percentile": 736.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 682.67, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 682.67, "10th_percentile": 682.67, "90th_percentile": 682.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 682.67, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 682.67, "10th_percentile": 682.67, "90th_percentile": 682.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1130.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1130.25, "10th_percentile": 1130.25, "90th_percentile": 1130.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1130.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1130.25, "10th_percentile": 1130.25, "90th_percentile": 1130.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 960.71, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 960.71, "10th_percentile": 960.71, "90th_percentile": 960.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 988.97, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 988.97, "10th_percentile": 988.97, "90th_percentile": 988.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 287.08, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 287.08, "10th_percentile": 287.08, "90th_percentile": 287.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1130.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1130.25, "10th_percentile": 1130.25, "90th_percentile": 1130.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 508.61, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 508.61, "10th_percentile": 508.61, "90th_percentile": 508.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 904.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 904.2, "10th_percentile": 904.2, "90th_percentile": 904.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 736.36, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 736.36, "10th_percentile": 736.36, "90th_percentile": 736.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 614.29, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 614.29, "10th_percentile": 614.29, "90th_percentile": 614.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 923.41, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 923.41, "10th_percentile": 923.41, "90th_percentile": 923.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 393.33, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 393.33, "10th_percentile": 393.33, "90th_percentile": 393.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 77.99, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 77.99, "10th_percentile": 77.99, "90th_percentile": 77.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 77.99, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 77.99, "10th_percentile": 77.99, "90th_percentile": 77.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 77.99, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 77.99, "10th_percentile": 77.99, "90th_percentile": 77.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 77.99, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 77.99, "10th_percentile": 77.99, "90th_percentile": 77.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 77.99, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 77.99, "10th_percentile": 77.99, "90th_percentile": 77.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 77.99, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 77.99, "10th_percentile": 77.99, "90th_percentile": 77.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_algorithm": "No contract line matched", "median_amount": 1130.25, "10th_percentile": 1130.25, "90th_percentile": 1130.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_algorithm": "No contract line matched", "median_amount": 1130.25, "10th_percentile": 1130.25, "90th_percentile": 1130.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_algorithm": "No contract line matched", "median_amount": 1130.25, "10th_percentile": 1130.25, "90th_percentile": 1130.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_algorithm": "No contract line matched", "median_amount": 1130.25, "10th_percentile": 1130.25, "90th_percentile": 1130.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "FLUOXETINE 10 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-10069", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "50111-0647-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2.5, "setting": "outpatient", "gross_charge": 2.5, "discounted_cash": 1.75, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.48, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1.21, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.21, "10th_percentile": 1.21, "90th_percentile": 1.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1.88, "10th_percentile": 1.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.63, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2.19, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2.19, "10th_percentile": 2.19, "90th_percentile": 2.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1.69, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2.04, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.04, "10th_percentile": 2.04, "90th_percentile": 2.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 2.13, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1.36, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1.26, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1.67, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.67, "10th_percentile": 1.67, "90th_percentile": 1.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1.73, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.64, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 0.64, "10th_percentile": 0.64, "90th_percentile": 0.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 0.87, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 0.87, "10th_percentile": 0.87, "90th_percentile": 0.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1.64, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.64, "10th_percentile": 1.64, "90th_percentile": 1.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 0.48, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.48, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.41, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.58, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.58, "10th_percentile": 1.58, "90th_percentile": 1.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.63, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2.04, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.04, "10th_percentile": 2.04, "90th_percentile": 2.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.68, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.4, "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": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "FLUTICASONE FUROATE-VILANTEROL 200-25 MCG/DOSE INH DSDV", "drug_information": { "unit": 28.0, "type": "UN" }, "code_information": [ { "code": "RX-204762", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00173-0882-14", "type": "NDC" } ], "standard_charges": [ { "minimum": 320.06, "maximum": 1684.5, "setting": "outpatient", "gross_charge": 1684.5, "discounted_cash": 1179.15, "payers_information": [ { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1684.5, "10th_percentile": 1684.5, "90th_percentile": 1684.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1684.5, "10th_percentile": 1684.5, "90th_percentile": 1684.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1684.5, "10th_percentile": 1684.5, "90th_percentile": 1684.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1684.5, "10th_percentile": 1684.5, "90th_percentile": 1684.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1684.5, "10th_percentile": 1684.5, "90th_percentile": 1684.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1684.5, "10th_percentile": 1684.5, "90th_percentile": 1684.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1473.94, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1473.94, "10th_percentile": 1473.94, "90th_percentile": 1473.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1347.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1347.6, "10th_percentile": 1347.6, "90th_percentile": 1347.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 915.53, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 915.53, "10th_percentile": 915.53, "90th_percentile": 915.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 845.62, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 845.62, "10th_percentile": 845.62, "90th_percentile": 845.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1126.93, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1126.93, "10th_percentile": 1126.93, "90th_percentile": 1126.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1684.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1684.5, "10th_percentile": 1684.5, "90th_percentile": 1684.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1684.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1684.5, "10th_percentile": 1684.5, "90th_percentile": 1684.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1101.66, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1101.66, "10th_percentile": 1101.66, "90th_percentile": 1101.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1167.36, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1167.36, "10th_percentile": 1167.36, "90th_percentile": 1167.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 586.21, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 586.21, "10th_percentile": 586.21, "90th_percentile": 586.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 427.86, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 427.86, "10th_percentile": 427.86, "90th_percentile": 427.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 320.06, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 320.06, "10th_percentile": 320.06, "90th_percentile": 320.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1097.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1097.45, "10th_percentile": 1097.45, "90th_percentile": 1097.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1372.87, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1372.87, "10th_percentile": 1372.87, "90th_percentile": 1372.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 320.06, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 320.06, "10th_percentile": 320.06, "90th_percentile": 320.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1129.63, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1129.63, "10th_percentile": 1129.63, "90th_percentile": 1129.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1063.09, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1063.09, "10th_percentile": 1063.09, "90th_percentile": 1063.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 949.22, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 949.22, "10th_percentile": 949.22, "90th_percentile": 949.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1097.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1097.45, "10th_percentile": 1097.45, "90th_percentile": 1097.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 941.64, "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": 941.64, "10th_percentile": 941.64, "90th_percentile": 941.64, "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": "VWH BCBS PPO", "standard_charge_dollar": 1372.87, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1372.87, "10th_percentile": 1372.87, "90th_percentile": 1372.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1135.35, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1135.35, "10th_percentile": 1135.35, "90th_percentile": 1135.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 763.08, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 763.08, "10th_percentile": 763.08, "90th_percentile": 763.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 813.61, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 813.61, "10th_percentile": 813.61, "90th_percentile": 813.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 320.06, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 320.06, "10th_percentile": 320.06, "90th_percentile": 320.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1431.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1431.83, "10th_percentile": 1431.83, "90th_percentile": 1431.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 758.03, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 758.03, "10th_percentile": 758.03, "90th_percentile": 758.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1263.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1263.38, "10th_percentile": 1263.38, "90th_percentile": 1263.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1684.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1684.5, "10th_percentile": 1684.5, "90th_percentile": 1684.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "FOLLOWER HEYMAN 12FRX13.35IN", "code_information": [ { "code": "SUP-318804", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 77.68, "maximum": 408.83, "setting": "outpatient", "gross_charge": 408.83, "discounted_cash": 286.18, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 408.83, "10th_percentile": 408.83, "90th_percentile": 408.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 408.83, "10th_percentile": 408.83, "90th_percentile": 408.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 408.83, "10th_percentile": 408.83, "90th_percentile": 408.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 408.83, "10th_percentile": 408.83, "90th_percentile": 408.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 408.83, "10th_percentile": 408.83, "90th_percentile": 408.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 408.83, "10th_percentile": 408.83, "90th_percentile": 408.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 77.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 77.68, "10th_percentile": 77.68, "90th_percentile": 77.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 357.73, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 357.73, "10th_percentile": 357.73, "90th_percentile": 357.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 275.55, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 275.55, "10th_percentile": 275.55, "90th_percentile": 275.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 333.2, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 333.2, "10th_percentile": 333.2, "90th_percentile": 333.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 185.2, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 185.2, "10th_percentile": 185.2, "90th_percentile": 185.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 183.97, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 183.97, "10th_percentile": 183.97, "90th_percentile": 183.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 347.51, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 347.51, "10th_percentile": 347.51, "90th_percentile": 347.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 197.46, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.46, "10th_percentile": 197.46, "90th_percentile": 197.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 266.35, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 266.35, "10th_percentile": 266.35, "90th_percentile": 266.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 327.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 327.06, "10th_percentile": 327.06, "90th_percentile": 327.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 222.2, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 222.2, "10th_percentile": 222.2, "90th_percentile": 222.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 306.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 306.62, "10th_percentile": 306.62, "90th_percentile": 306.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 408.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 408.83, "10th_percentile": 408.83, "90th_percentile": 408.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 273.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 273.51, "10th_percentile": 273.51, "90th_percentile": 273.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 205.23, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.23, "10th_percentile": 205.23, "90th_percentile": 205.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 103.84, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 103.84, "10th_percentile": 103.84, "90th_percentile": 103.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 283.32, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 283.32, "10th_percentile": 283.32, "90th_percentile": 283.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 142.27, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 142.27, "10th_percentile": 142.27, "90th_percentile": 142.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 267.37, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 267.37, "10th_percentile": 267.37, "90th_percentile": 267.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 408.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 408.83, "10th_percentile": 408.83, "90th_percentile": 408.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 408.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 408.83, "10th_percentile": 408.83, "90th_percentile": 408.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 77.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 77.68, "10th_percentile": 77.68, "90th_percentile": 77.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 77.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 77.68, "10th_percentile": 77.68, "90th_percentile": 77.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 228.54, "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": 228.54, "10th_percentile": 228.54, "90th_percentile": 228.54, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 230.38, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 230.38, "10th_percentile": 230.38, "90th_percentile": 230.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 274.16, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.16, "10th_percentile": 274.16, "90th_percentile": 274.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 333.2, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 333.2, "10th_percentile": 333.2, "90th_percentile": 333.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 258.01, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.01, "10th_percentile": 258.01, "90th_percentile": 258.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 266.35, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 266.35, "10th_percentile": 266.35, "90th_percentile": 266.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "FONDAPARINUX 10 MG/0.8 ML SUBQ SYRG", "drug_information": { "unit": 0.8, "type": "ML" }, "code_information": [ { "code": "RX-98215", "type": "CDM" }, { "code": "J1652", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "55111-0681-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.76, "maximum": 445.75, "setting": "outpatient", "gross_charge": 445.75, "discounted_cash": 312.02, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 84.69, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 84.69, "10th_percentile": 84.69, "90th_percentile": 84.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 84.69, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 84.69, "10th_percentile": 84.69, "90th_percentile": 84.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 84.69, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 84.69, "10th_percentile": 84.69, "90th_percentile": 84.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 280.82, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 280.82, "10th_percentile": 280.82, "90th_percentile": 280.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 364.18, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 364.18, "10th_percentile": 364.18, "90th_percentile": 364.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 249.17, "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": 249.17, "10th_percentile": 249.17, "90th_percentile": 249.17, "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": "VWH BCBS HMO", "standard_charge_dollar": 290.41, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 290.41, "10th_percentile": 290.41, "90th_percentile": 290.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 269.23, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 269.23, "10th_percentile": 269.23, "90th_percentile": 269.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 269.23, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 269.23, "10th_percentile": 269.23, "90th_percentile": 269.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 445.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 445.75, "10th_percentile": 445.75, "90th_percentile": 445.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 445.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 445.75, "10th_percentile": 445.75, "90th_percentile": 445.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 378.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 378.89, "10th_percentile": 378.89, "90th_percentile": 378.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 390.03, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 390.03, "10th_percentile": 390.03, "90th_percentile": 390.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 113.22, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 113.22, "10th_percentile": 113.22, "90th_percentile": 113.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 445.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 445.75, "10th_percentile": 445.75, "90th_percentile": 445.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 200.59, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 200.59, "10th_percentile": 200.59, "90th_percentile": 200.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 356.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 356.6, "10th_percentile": 356.6, "90th_percentile": 356.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 290.41, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 290.41, "10th_percentile": 290.41, "90th_percentile": 290.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 242.27, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 242.27, "10th_percentile": 242.27, "90th_percentile": 242.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 300.44, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 300.44, "10th_percentile": 300.44, "90th_percentile": 300.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 334.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 334.31, "10th_percentile": 334.31, "90th_percentile": 334.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 364.18, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 364.18, "10th_percentile": 364.18, "90th_percentile": 364.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 155.12, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 155.12, "10th_percentile": 155.12, "90th_percentile": 155.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 30.76, "10th_percentile": 30.76, "90th_percentile": 30.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 30.76, "10th_percentile": 30.76, "90th_percentile": 30.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 30.76, "10th_percentile": 30.76, "90th_percentile": 30.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 30.76, "10th_percentile": 30.76, "90th_percentile": 30.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 30.76, "10th_percentile": 30.76, "90th_percentile": 30.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 30.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 30.76, "10th_percentile": 30.76, "90th_percentile": 30.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "FORCEPS BX ENDOSCP RAD JAW 4 L M00513332", "code_information": [ { "code": "SUP-134747", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 23.66, "maximum": 124.52, "setting": "outpatient", "gross_charge": 124.52, "discounted_cash": 87.16, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 124.52, "10th_percentile": 124.52, "90th_percentile": 124.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 124.52, "10th_percentile": 124.52, "90th_percentile": 124.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 124.52, "10th_percentile": 124.52, "90th_percentile": 124.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 124.52, "10th_percentile": 124.52, "90th_percentile": 124.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 124.52, "10th_percentile": 124.52, "90th_percentile": 124.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 124.52, "10th_percentile": 124.52, "90th_percentile": 124.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 23.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 23.66, "10th_percentile": 23.66, "90th_percentile": 23.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 108.96, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 108.96, "10th_percentile": 108.96, "90th_percentile": 108.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 83.93, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 83.93, "10th_percentile": 83.93, "90th_percentile": 83.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 101.48, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.48, "10th_percentile": 101.48, "90th_percentile": 101.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 56.41, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.41, "10th_percentile": 56.41, "90th_percentile": 56.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 56.03, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 56.03, "10th_percentile": 56.03, "90th_percentile": 56.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 105.84, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 105.84, "10th_percentile": 105.84, "90th_percentile": 105.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 60.14, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.14, "10th_percentile": 60.14, "90th_percentile": 60.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 81.12, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 81.12, "10th_percentile": 81.12, "90th_percentile": 81.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 99.62, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 99.62, "10th_percentile": 99.62, "90th_percentile": 99.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 67.68, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 67.68, "10th_percentile": 67.68, "90th_percentile": 67.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 93.39, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 93.39, "10th_percentile": 93.39, "90th_percentile": 93.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 124.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 124.52, "10th_percentile": 124.52, "90th_percentile": 124.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 83.3, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 83.3, "10th_percentile": 83.3, "90th_percentile": 83.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 62.51, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.51, "10th_percentile": 62.51, "90th_percentile": 62.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 31.63, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 31.63, "10th_percentile": 31.63, "90th_percentile": 31.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 86.29, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.29, "10th_percentile": 86.29, "90th_percentile": 86.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 43.33, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 43.33, "10th_percentile": 43.33, "90th_percentile": 43.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 81.44, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.44, "10th_percentile": 81.44, "90th_percentile": 81.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 124.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 124.52, "10th_percentile": 124.52, "90th_percentile": 124.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 124.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 124.52, "10th_percentile": 124.52, "90th_percentile": 124.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 23.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 23.66, "10th_percentile": 23.66, "90th_percentile": 23.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 23.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 23.66, "10th_percentile": 23.66, "90th_percentile": 23.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 69.61, "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": 69.61, "10th_percentile": 69.61, "90th_percentile": 69.61, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 70.17, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.17, "10th_percentile": 70.17, "90th_percentile": 70.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 83.5, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 83.5, "10th_percentile": 83.5, "90th_percentile": 83.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 101.48, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.48, "10th_percentile": 101.48, "90th_percentile": 101.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 78.58, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.58, "10th_percentile": 78.58, "90th_percentile": 78.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 81.12, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 81.12, "10th_percentile": 81.12, "90th_percentile": 81.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "FUROSEMIDE 10 MG/ML ORAL SOLN", "drug_information": { "unit": 2.0, "type": "ML" }, "code_information": [ { "code": "RX-3292", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00054-3294-46", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.33, "maximum": 12.25, "setting": "outpatient", "gross_charge": 12.25, "discounted_cash": 8.57, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 6.66, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 6.66, "10th_percentile": 6.66, "90th_percentile": 6.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 9.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 9.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 9.19, "10th_percentile": 9.19, "90th_percentile": 9.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 8.26, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 8.26, "10th_percentile": 8.26, "90th_percentile": 8.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 5.55, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.55, "10th_percentile": 5.55, "90th_percentile": 5.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 7.98, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 7.98, "10th_percentile": 7.98, "90th_percentile": 7.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 5.92, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.92, "10th_percentile": 5.92, "90th_percentile": 5.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 10.72, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 10.72, "10th_percentile": 10.72, "90th_percentile": 10.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 5.51, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 10.41, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 10.41, "10th_percentile": 10.41, "90th_percentile": 10.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 9.98, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.98, "10th_percentile": 9.98, "90th_percentile": 9.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 2.33, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2.33, "10th_percentile": 2.33, "90th_percentile": 2.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 8.2, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.2, "10th_percentile": 8.2, "90th_percentile": 8.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 6.15, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.15, "10th_percentile": 6.15, "90th_percentile": 6.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 8.01, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.01, "10th_percentile": 8.01, "90th_percentile": 8.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 8.49, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.49, "10th_percentile": 8.49, "90th_percentile": 8.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 4.26, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 4.26, "10th_percentile": 4.26, "90th_percentile": 4.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.11, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% 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 Services; 25.4% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2.33, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2.33, "10th_percentile": 2.33, "90th_percentile": 2.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2.33, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2.33, "10th_percentile": 2.33, "90th_percentile": 2.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.73, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.73, "10th_percentile": 7.73, "90th_percentile": 7.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 9.98, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.98, "10th_percentile": 9.98, "90th_percentile": 9.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 7.98, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 7.98, "10th_percentile": 7.98, "90th_percentile": 7.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.9, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.9, "10th_percentile": 6.9, "90th_percentile": 6.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.85, "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": 6.85, "10th_percentile": 6.85, "90th_percentile": 6.85, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.21, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.21, "10th_percentile": 8.21, "90th_percentile": 8.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "GABAPENTIN 100 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-18309", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0580-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.95, "maximum": 5.0, "setting": "outpatient", "gross_charge": 5.0, "discounted_cash": 3.5, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 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": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2.42, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.42, "10th_percentile": 2.42, "90th_percentile": 2.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.27, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.27, "10th_percentile": 2.27, "90th_percentile": 2.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient 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": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3.26, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3.26, "10th_percentile": 3.26, "90th_percentile": 3.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4.38, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4.38, "10th_percentile": 4.38, "90th_percentile": 4.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3.37, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3.37, "10th_percentile": 3.37, "90th_percentile": 3.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4.08, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.08, "10th_percentile": 4.08, "90th_percentile": 4.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 4.25, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 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 Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2.72, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2.72, "10th_percentile": 2.72, "90th_percentile": 2.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2.51, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.51, "10th_percentile": 2.51, "90th_percentile": 2.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3.35, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.35, "10th_percentile": 3.35, "90th_percentile": 3.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3.47, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.47, "10th_percentile": 3.47, "90th_percentile": 3.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.27, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1.27, "10th_percentile": 1.27, "90th_percentile": 1.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1.74, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1.74, "10th_percentile": 1.74, "90th_percentile": 1.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3.27, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.27, "10th_percentile": 3.27, "90th_percentile": 3.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.82, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.82, "10th_percentile": 2.82, "90th_percentile": 2.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.16, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3.26, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3.26, "10th_percentile": 3.26, "90th_percentile": 3.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4.08, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.08, "10th_percentile": 4.08, "90th_percentile": 4.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.35, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "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" } ] } ] }, { "description": "GABAPENTIN 300 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-18308", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00904-6666-61", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.86, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.86, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.86, "10th_percentile": 0.86, "90th_percentile": 0.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 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": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2.17, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.17, "10th_percentile": 2.17, "90th_percentile": 2.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.04, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.04, "10th_percentile": 2.04, "90th_percentile": 2.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient 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": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2.03, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2.03, "10th_percentile": 2.03, "90th_percentile": 2.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2.93, "10th_percentile": 2.93, "90th_percentile": 2.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 3.94, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 3.94, "10th_percentile": 3.94, "90th_percentile": 3.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3.03, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3.03, "10th_percentile": 3.03, "90th_percentile": 3.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3.67, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.67, "10th_percentile": 3.67, "90th_percentile": 3.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 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 Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2.45, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2.45, "10th_percentile": 2.45, "90th_percentile": 2.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2.26, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.26, "10th_percentile": 2.26, "90th_percentile": 2.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3.01, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.01, "10th_percentile": 3.01, "90th_percentile": 3.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3.12, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.12, "10th_percentile": 3.12, "90th_percentile": 3.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.14, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% 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; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1.57, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1.57, "10th_percentile": 1.57, "90th_percentile": 1.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2.94, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 0.86, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.86, "10th_percentile": 0.86, "90th_percentile": 0.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.86, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.86, "10th_percentile": 0.86, "90th_percentile": 0.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH 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": "MULTIPLAN/PHCS [142]", "plan_name": "VWH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.54, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.54, "10th_percentile": 2.54, "90th_percentile": 2.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.84, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2.93, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2.93, "10th_percentile": 2.93, "90th_percentile": 2.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3.67, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.67, "10th_percentile": 3.67, "90th_percentile": 3.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.02, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.02, "10th_percentile": 3.02, "90th_percentile": 3.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "GADOBUTROL 1 MMOL/ML (604.72 MG/ML) IV SOLN", "drug_information": { "unit": 65.0, "type": "ML" }, "code_information": [ { "code": "RX-189150", "type": "CDM" }, { "code": "A9585", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "50419-0325-15", "type": "NDC" } ], "standard_charges": [ { "minimum": 277.33, "maximum": 4019.25, "setting": "outpatient", "gross_charge": 4019.25, "discounted_cash": 2813.47, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 763.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 763.66, "10th_percentile": 763.66, "90th_percentile": 763.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 763.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 763.66, "10th_percentile": 763.66, "90th_percentile": 763.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 763.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 763.66, "10th_percentile": 763.66, "90th_percentile": 763.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2532.13, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2532.13, "10th_percentile": 2532.13, "90th_percentile": 2532.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3283.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3283.73, "10th_percentile": 3283.73, "90th_percentile": 3283.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2246.76, "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": 2246.76, "10th_percentile": 2246.76, "90th_percentile": 2246.76, "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": "VWH BCBS HMO", "standard_charge_dollar": 2618.54, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2618.54, "10th_percentile": 2618.54, "90th_percentile": 2618.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2427.63, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2427.63, "10th_percentile": 2427.63, "90th_percentile": 2427.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2427.63, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2427.63, "10th_percentile": 2427.63, "90th_percentile": 2427.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4019.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4019.25, "10th_percentile": 4019.25, "90th_percentile": 4019.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4019.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4019.25, "10th_percentile": 4019.25, "90th_percentile": 4019.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 3416.36, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 3416.36, "10th_percentile": 3416.36, "90th_percentile": 3416.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 3516.84, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 3516.84, "10th_percentile": 3516.84, "90th_percentile": 3516.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1020.89, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1020.89, "10th_percentile": 1020.89, "90th_percentile": 1020.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4019.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4019.25, "10th_percentile": 4019.25, "90th_percentile": 4019.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1808.66, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1808.66, "10th_percentile": 1808.66, "90th_percentile": 1808.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 3215.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 3215.4, "10th_percentile": 3215.4, "90th_percentile": 3215.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2618.54, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2618.54, "10th_percentile": 2618.54, "90th_percentile": 2618.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2184.46, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2184.46, "10th_percentile": 2184.46, "90th_percentile": 2184.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2708.97, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2708.97, "10th_percentile": 2708.97, "90th_percentile": 2708.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3014.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 3014.44, "10th_percentile": 3014.44, "90th_percentile": 3014.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3283.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3283.73, "10th_percentile": 3283.73, "90th_percentile": 3283.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1398.7, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1398.7, "10th_percentile": 1398.7, "90th_percentile": 1398.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2785.34, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2785.34, "10th_percentile": 2785.34, "90th_percentile": 2785.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2628.59, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2628.59, "10th_percentile": 2628.59, "90th_percentile": 2628.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 277.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 277.33, "10th_percentile": 277.33, "90th_percentile": 277.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 277.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 277.33, "10th_percentile": 277.33, "90th_percentile": 277.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 277.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 277.33, "10th_percentile": 277.33, "90th_percentile": 277.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 277.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 277.33, "10th_percentile": 277.33, "90th_percentile": 277.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 277.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 277.33, "10th_percentile": 277.33, "90th_percentile": 277.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 277.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 277.33, "10th_percentile": 277.33, "90th_percentile": 277.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "GELPORT (C8XX2)", "code_information": [ { "code": "SUP-57784", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 896.7, "maximum": 4719.47, "setting": "outpatient", "gross_charge": 4719.47, "discounted_cash": 3303.63, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4719.47, "10th_percentile": 4719.47, "90th_percentile": 4719.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4719.47, "10th_percentile": 4719.47, "90th_percentile": 4719.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4719.47, "10th_percentile": 4719.47, "90th_percentile": 4719.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4719.47, "10th_percentile": 4719.47, "90th_percentile": 4719.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4719.47, "10th_percentile": 4719.47, "90th_percentile": 4719.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4719.47, "10th_percentile": 4719.47, "90th_percentile": 4719.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 896.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 896.7, "10th_percentile": 896.7, "90th_percentile": 896.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4129.54, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4129.54, "10th_percentile": 4129.54, "90th_percentile": 4129.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3180.92, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3180.92, "10th_percentile": 3180.92, "90th_percentile": 3180.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3846.37, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3846.37, "10th_percentile": 3846.37, "90th_percentile": 3846.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2137.92, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2137.92, "10th_percentile": 2137.92, "90th_percentile": 2137.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2123.76, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2123.76, "10th_percentile": 2123.76, "90th_percentile": 2123.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 4011.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4011.55, "10th_percentile": 4011.55, "90th_percentile": 4011.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2279.5, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2279.5, "10th_percentile": 2279.5, "90th_percentile": 2279.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3074.73, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3074.73, "10th_percentile": 3074.73, "90th_percentile": 3074.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 3775.58, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 3775.58, "10th_percentile": 3775.58, "90th_percentile": 3775.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2565.03, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2565.03, "10th_percentile": 2565.03, "90th_percentile": 2565.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3539.6, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 3539.6, "10th_percentile": 3539.6, "90th_percentile": 3539.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4719.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4719.47, "10th_percentile": 4719.47, "90th_percentile": 4719.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3157.33, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3157.33, "10th_percentile": 3157.33, "90th_percentile": 3157.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2369.17, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2369.17, "10th_percentile": 2369.17, "90th_percentile": 2369.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1198.75, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1198.75, "10th_percentile": 1198.75, "90th_percentile": 1198.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3270.59, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3270.59, "10th_percentile": 3270.59, "90th_percentile": 3270.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1642.38, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1642.38, "10th_percentile": 1642.38, "90th_percentile": 1642.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3086.53, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3086.53, "10th_percentile": 3086.53, "90th_percentile": 3086.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4719.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4719.47, "10th_percentile": 4719.47, "90th_percentile": 4719.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4719.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4719.47, "10th_percentile": 4719.47, "90th_percentile": 4719.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 896.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 896.7, "10th_percentile": 896.7, "90th_percentile": 896.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 896.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 896.7, "10th_percentile": 896.7, "90th_percentile": 896.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2638.18, "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": 2638.18, "10th_percentile": 2638.18, "90th_percentile": 2638.18, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2659.42, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2659.42, "10th_percentile": 2659.42, "90th_percentile": 2659.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3164.88, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3164.88, "10th_percentile": 3164.88, "90th_percentile": 3164.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3846.37, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3846.37, "10th_percentile": 3846.37, "90th_percentile": 3846.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2978.46, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2978.46, "10th_percentile": 2978.46, "90th_percentile": 2978.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3074.73, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3074.73, "10th_percentile": 3074.73, "90th_percentile": 3074.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) IV SOLN", "drug_information": { "unit": 52.6, "type": "ML" }, "code_information": [ { "code": "RX-192248", "type": "CDM" }, { "code": "J9201", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-0182-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.0, "maximum": 594.25, "setting": "outpatient", "gross_charge": 594.25, "discounted_cash": 415.97, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 112.91, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 112.91, "10th_percentile": 112.91, "90th_percentile": 112.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 112.91, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 112.91, "10th_percentile": 112.91, "90th_percentile": 112.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 112.91, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 112.91, "10th_percentile": 112.91, "90th_percentile": 112.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 374.38, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 374.38, "10th_percentile": 374.38, "90th_percentile": 374.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 485.5, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 485.5, "10th_percentile": 485.5, "90th_percentile": 485.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 332.19, "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": 332.19, "10th_percentile": 332.19, "90th_percentile": 332.19, "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 387.15, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 387.15, "10th_percentile": 387.15, "90th_percentile": 387.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 358.93, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 358.93, "10th_percentile": 358.93, "90th_percentile": 358.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 358.93, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 358.93, "10th_percentile": 358.93, "90th_percentile": 358.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 594.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 594.25, "10th_percentile": 594.25, "90th_percentile": 594.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 594.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 594.25, "10th_percentile": 594.25, "90th_percentile": 594.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 505.11, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 505.11, "10th_percentile": 505.11, "90th_percentile": 505.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 519.97, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 519.97, "10th_percentile": 519.97, "90th_percentile": 519.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 150.94, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 150.94, "10th_percentile": 150.94, "90th_percentile": 150.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 594.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 594.25, "10th_percentile": 594.25, "90th_percentile": 594.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 267.41, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 267.41, "10th_percentile": 267.41, "90th_percentile": 267.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 475.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 475.4, "10th_percentile": 475.4, "90th_percentile": 475.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 387.15, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 387.15, "10th_percentile": 387.15, "90th_percentile": 387.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 322.97, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 322.97, "10th_percentile": 322.97, "90th_percentile": 322.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 400.52, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 400.52, "10th_percentile": 400.52, "90th_percentile": 400.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 445.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 445.69, "10th_percentile": 445.69, "90th_percentile": 445.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 485.5, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 485.5, "10th_percentile": 485.5, "90th_percentile": 485.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 206.8, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 206.8, "10th_percentile": 206.8, "90th_percentile": 206.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 41.0, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 41.0, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 41.0, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 41.0, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 41.0, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 41.0, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 41.0, "10th_percentile": 41.0, "90th_percentile": 41.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "GEN LAPAROSCOPY CDS CUSTOM VW", "code_information": [ { "code": "SUP-334091", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 475.64, "maximum": 2503.36, "setting": "outpatient", "gross_charge": 2503.36, "discounted_cash": 1752.35, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2503.36, "10th_percentile": 2503.36, "90th_percentile": 2503.36, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2503.36, "10th_percentile": 2503.36, "90th_percentile": 2503.36, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2503.36, "10th_percentile": 2503.36, "90th_percentile": 2503.36, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2503.36, "10th_percentile": 2503.36, "90th_percentile": 2503.36, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2503.36, "10th_percentile": 2503.36, "90th_percentile": 2503.36, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2503.36, "10th_percentile": 2503.36, "90th_percentile": 2503.36, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 475.64, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 475.64, "10th_percentile": 475.64, "90th_percentile": 475.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2190.44, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2190.44, "10th_percentile": 2190.44, "90th_percentile": 2190.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1687.26, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1687.26, "10th_percentile": 1687.26, "90th_percentile": 1687.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2040.24, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2040.24, "10th_percentile": 2040.24, "90th_percentile": 2040.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1134.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1134.02, "10th_percentile": 1134.02, "90th_percentile": 1134.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1126.51, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1126.51, "10th_percentile": 1126.51, "90th_percentile": 1126.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2127.86, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2127.86, "10th_percentile": 2127.86, "90th_percentile": 2127.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1209.12, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1209.12, "10th_percentile": 1209.12, "90th_percentile": 1209.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1630.94, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1630.94, "10th_percentile": 1630.94, "90th_percentile": 1630.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2002.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2002.69, "10th_percentile": 2002.69, "90th_percentile": 2002.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1360.58, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1360.58, "10th_percentile": 1360.58, "90th_percentile": 1360.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1877.52, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1877.52, "10th_percentile": 1877.52, "90th_percentile": 1877.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2503.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2503.36, "10th_percentile": 2503.36, "90th_percentile": 2503.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1674.75, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1674.75, "10th_percentile": 1674.75, "90th_percentile": 1674.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1256.69, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1256.69, "10th_percentile": 1256.69, "90th_percentile": 1256.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 635.85, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 635.85, "10th_percentile": 635.85, "90th_percentile": 635.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1734.83, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1734.83, "10th_percentile": 1734.83, "90th_percentile": 1734.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 871.17, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 871.17, "10th_percentile": 871.17, "90th_percentile": 871.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1637.2, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1637.2, "10th_percentile": 1637.2, "90th_percentile": 1637.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2503.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2503.36, "10th_percentile": 2503.36, "90th_percentile": 2503.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2503.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2503.36, "10th_percentile": 2503.36, "90th_percentile": 2503.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 475.64, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 475.64, "10th_percentile": 475.64, "90th_percentile": 475.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 475.64, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 475.64, "10th_percentile": 475.64, "90th_percentile": 475.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1399.38, "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": 1399.38, "10th_percentile": 1399.38, "90th_percentile": 1399.38, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1410.64, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1410.64, "10th_percentile": 1410.64, "90th_percentile": 1410.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1678.75, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1678.75, "10th_percentile": 1678.75, "90th_percentile": 1678.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2040.24, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2040.24, "10th_percentile": 2040.24, "90th_percentile": 2040.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1579.87, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1579.87, "10th_percentile": 1579.87, "90th_percentile": 1579.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1630.94, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1630.94, "10th_percentile": 1630.94, "90th_percentile": 1630.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "GLIMEPIRIDE 1 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-16355", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "55111-0320-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.38, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.97, "10th_percentile": 0.97, "90th_percentile": 0.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 0.9, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.3, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.3, "10th_percentile": 1.3, "90th_percentile": 1.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1.75, "10th_percentile": 1.75, "90th_percentile": 1.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1.35, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.63, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1.09, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1.09, "10th_percentile": 1.09, "90th_percentile": 1.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1.34, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.34, "10th_percentile": 1.34, "90th_percentile": 1.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1.39, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.39, "10th_percentile": 1.39, "90th_percentile": 1.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.51, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 0.51, "10th_percentile": 0.51, "90th_percentile": 0.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 0.7, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1.31, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.31, "10th_percentile": 1.31, "90th_percentile": 1.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.13, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.3, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.3, "10th_percentile": 1.3, "90th_percentile": 1.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.63, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.34, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.34, "10th_percentile": 1.34, "90th_percentile": 1.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.12, "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": 1.12, "10th_percentile": 1.12, "90th_percentile": 1.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "GLIPIZIDE 5 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-10117", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "50268-0361-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.76, "maximum": 9.25, "setting": "outpatient", "gross_charge": 9.25, "discounted_cash": 6.47, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1.76, "10th_percentile": 1.76, "90th_percentile": 1.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 7.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 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": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 4.47, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.47, "10th_percentile": 4.47, "90th_percentile": 4.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 4.19, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.19, "10th_percentile": 4.19, "90th_percentile": 4.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 6.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient 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": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 4.16, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 4.16, "10th_percentile": 4.16, "90th_percentile": 4.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 6.03, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 6.03, "10th_percentile": 6.03, "90th_percentile": 6.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 8.09, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 8.09, "10th_percentile": 8.09, "90th_percentile": 8.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 6.23, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 6.23, "10th_percentile": 6.23, "90th_percentile": 6.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 7.54, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.54, "10th_percentile": 7.54, "90th_percentile": 7.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 7.86, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 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 Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 5.03, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 5.03, "10th_percentile": 5.03, "90th_percentile": 5.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 4.64, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.64, "10th_percentile": 4.64, "90th_percentile": 4.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 6.19, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.19, "10th_percentile": 6.19, "90th_percentile": 6.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 6.41, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.41, "10th_percentile": 6.41, "90th_percentile": 6.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.35, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 2.35, "10th_percentile": 2.35, "90th_percentile": 2.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 3.22, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 3.22, "10th_percentile": 3.22, "90th_percentile": 3.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 6.05, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.05, "10th_percentile": 6.05, "90th_percentile": 6.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 1.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1.76, "10th_percentile": 1.76, "90th_percentile": 1.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1.76, "10th_percentile": 1.76, "90th_percentile": 1.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH 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": "MULTIPLAN/PHCS [142]", "plan_name": "VWH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5.21, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.84, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.84, "10th_percentile": 5.84, "90th_percentile": 5.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 6.03, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 6.03, "10th_percentile": 6.03, "90th_percentile": 6.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 7.54, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.54, "10th_percentile": 7.54, "90th_percentile": 7.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6.2, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "VWH ILLINOIS MEDICAID", "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": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "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": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "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" } ] } ] }, { "description": "GLUCAGON HCL 1 MG/ML INJ SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-204778", "type": "CDM" }, { "code": "J1611", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "63323-0593-03", "type": "NDC" } ], "standard_charges": [ { "minimum": 89.84, "maximum": 1302.0, "setting": "outpatient", "gross_charge": 1302.0, "discounted_cash": 911.4, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.0, "10th_percentile": 1302.0, "90th_percentile": 1302.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.0, "10th_percentile": 1302.0, "90th_percentile": 1302.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1063.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1063.73, "10th_percentile": 1063.73, "90th_percentile": 1063.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH THE ALLIANCE", "standard_charge_dollar": 707.64, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 707.64, "10th_percentile": 707.64, "90th_percentile": 707.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 848.25, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 848.25, "10th_percentile": 848.25, "90th_percentile": 848.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 330.71, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 330.71, "10th_percentile": 330.71, "90th_percentile": 330.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1139.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1139.25, "10th_percentile": 1139.25, "90th_percentile": 1139.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 585.9, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 585.9, "10th_percentile": 585.9, "90th_percentile": 585.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1106.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1106.7, "10th_percentile": 1106.7, "90th_percentile": 1106.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1041.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1041.6, "10th_percentile": 1041.6, "90th_percentile": 1041.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1302.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1302.0, "10th_percentile": 1302.0, "90th_percentile": 1302.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 976.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 976.5, "10th_percentile": 976.5, "90th_percentile": 976.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 453.1, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 453.1, "10th_percentile": 453.1, "90th_percentile": 453.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 877.55, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 877.55, "10th_percentile": 877.55, "90th_percentile": 877.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1063.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1063.73, "10th_percentile": 1063.73, "90th_percentile": 1063.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 820.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 820.26, "10th_percentile": 820.26, "90th_percentile": 820.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 848.25, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 848.25, "10th_percentile": 848.25, "90th_percentile": 848.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 727.82, "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": 727.82, "10th_percentile": 727.82, "90th_percentile": 727.82, "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 786.41, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 786.41, "10th_percentile": 786.41, "90th_percentile": 786.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 786.41, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 786.41, "10th_percentile": 786.41, "90th_percentile": 786.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 247.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 247.38, "10th_percentile": 247.38, "90th_percentile": 247.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 247.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 247.38, "10th_percentile": 247.38, "90th_percentile": 247.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 247.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 247.38, "10th_percentile": 247.38, "90th_percentile": 247.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 89.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 89.84, "10th_percentile": 89.84, "90th_percentile": 89.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 89.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 89.84, "10th_percentile": 89.84, "90th_percentile": 89.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 89.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 89.84, "10th_percentile": 89.84, "90th_percentile": 89.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 89.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 89.84, "10th_percentile": 89.84, "90th_percentile": 89.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 89.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 89.84, "10th_percentile": 89.84, "90th_percentile": 89.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 89.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 89.84, "10th_percentile": 89.84, "90th_percentile": 89.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "GLYCERIN (ADULT) RECT SUPP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-15053", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "46122-0221-63", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.43, "maximum": 2.25, "setting": "outpatient", "gross_charge": 2.25, "discounted_cash": 1.57, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 0.78, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.27, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1.91, "10th_percentile": 1.91, "90th_percentile": 1.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1.22, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1.52, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1.52, "10th_percentile": 1.52, "90th_percentile": 1.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1.97, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.42, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.42, "10th_percentile": 1.42, "90th_percentile": 1.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1.09, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.26, "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": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "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": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.57, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 0.57, "10th_percentile": 0.57, "90th_percentile": 0.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1.01, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1.01, "10th_percentile": 1.01, "90th_percentile": 1.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.51, "10th_percentile": 1.51, "90th_percentile": 1.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.51, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.51, "10th_percentile": 1.51, "90th_percentile": 1.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.83, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1.83, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 0.43, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "GLYCOPYRROLATE 0.2 MG/ML INJ SOLN", "drug_information": { "unit": 1.0, "type": "ML" }, "code_information": [ { "code": "RX-3497", "type": "CDM" }, { "code": "J1596", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "63323-0578-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.81, "maximum": 98.75, "setting": "outpatient", "gross_charge": 98.75, "discounted_cash": 69.12, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 34.37, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 34.37, "10th_percentile": 34.37, "90th_percentile": 34.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 74.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 74.06, "10th_percentile": 74.06, "90th_percentile": 74.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 83.94, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 83.94, "10th_percentile": 83.94, "90th_percentile": 83.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 44.44, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 44.44, "10th_percentile": 44.44, "90th_percentile": 44.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 53.67, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 53.67, "10th_percentile": 53.67, "90th_percentile": 53.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 66.56, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 66.56, "10th_percentile": 66.56, "90th_percentile": 66.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 86.41, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 86.41, "10th_percentile": 86.41, "90th_percentile": 86.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 64.34, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 64.34, "10th_percentile": 64.34, "90th_percentile": 64.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 79.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 79.0, "10th_percentile": 79.0, "90th_percentile": 79.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 98.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 98.75, "10th_percentile": 98.75, "90th_percentile": 98.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 25.08, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 25.08, "10th_percentile": 25.08, "90th_percentile": 25.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 80.68, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.68, "10th_percentile": 80.68, "90th_percentile": 80.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 98.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 98.75, "10th_percentile": 98.75, "90th_percentile": 98.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 98.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 98.75, "10th_percentile": 98.75, "90th_percentile": 98.75, "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": "VWH BCBS PPO", "standard_charge_dollar": 80.68, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.68, "10th_percentile": 80.68, "90th_percentile": 80.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 62.21, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.21, "10th_percentile": 62.21, "90th_percentile": 62.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 55.2, "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": 55.2, "10th_percentile": 55.2, "90th_percentile": 55.2, "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": "VWH BCBS HMO", "standard_charge_dollar": 64.34, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 64.34, "10th_percentile": 64.34, "90th_percentile": 64.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 59.65, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.65, "10th_percentile": 59.65, "90th_percentile": 59.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 59.65, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.65, "10th_percentile": 59.65, "90th_percentile": 59.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 18.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 18.76, "10th_percentile": 18.76, "90th_percentile": 18.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 18.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 18.76, "10th_percentile": 18.76, "90th_percentile": 18.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 18.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 18.76, "10th_percentile": 18.76, "90th_percentile": 18.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.81, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.81, "10th_percentile": 6.81, "90th_percentile": 6.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.81, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.81, "10th_percentile": 6.81, "90th_percentile": 6.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.81, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.81, "10th_percentile": 6.81, "90th_percentile": 6.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.81, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.81, "10th_percentile": 6.81, "90th_percentile": 6.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.81, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.81, "10th_percentile": 6.81, "90th_percentile": 6.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 6.81, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 6.81, "10th_percentile": 6.81, "90th_percentile": 6.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "GRID DISPOSABLE TEMPLATE STL", "code_information": [ { "code": "SUP-317174", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 149.26, "maximum": 785.59, "setting": "outpatient", "gross_charge": 785.59, "discounted_cash": 549.91, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 785.59, "10th_percentile": 785.59, "90th_percentile": 785.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 785.59, "10th_percentile": 785.59, "90th_percentile": 785.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 785.59, "10th_percentile": 785.59, "90th_percentile": 785.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 785.59, "10th_percentile": 785.59, "90th_percentile": 785.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 785.59, "10th_percentile": 785.59, "90th_percentile": 785.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 785.59, "10th_percentile": 785.59, "90th_percentile": 785.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 149.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 149.26, "10th_percentile": 149.26, "90th_percentile": 149.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 687.39, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 687.39, "10th_percentile": 687.39, "90th_percentile": 687.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 529.49, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 529.49, "10th_percentile": 529.49, "90th_percentile": 529.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 640.26, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 640.26, "10th_percentile": 640.26, "90th_percentile": 640.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 355.87, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 355.87, "10th_percentile": 355.87, "90th_percentile": 355.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 353.52, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 353.52, "10th_percentile": 353.52, "90th_percentile": 353.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 667.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 667.75, "10th_percentile": 667.75, "90th_percentile": 667.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 379.44, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 379.44, "10th_percentile": 379.44, "90th_percentile": 379.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 511.81, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 511.81, "10th_percentile": 511.81, "90th_percentile": 511.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 628.47, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 628.47, "10th_percentile": 628.47, "90th_percentile": 628.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 426.97, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 426.97, "10th_percentile": 426.97, "90th_percentile": 426.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 589.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 589.19, "10th_percentile": 589.19, "90th_percentile": 589.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 785.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 785.59, "10th_percentile": 785.59, "90th_percentile": 785.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 525.56, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 525.56, "10th_percentile": 525.56, "90th_percentile": 525.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 394.37, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 394.37, "10th_percentile": 394.37, "90th_percentile": 394.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 199.54, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 199.54, "10th_percentile": 199.54, "90th_percentile": 199.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 544.41, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 544.41, "10th_percentile": 544.41, "90th_percentile": 544.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 273.39, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 273.39, "10th_percentile": 273.39, "90th_percentile": 273.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 513.78, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 513.78, "10th_percentile": 513.78, "90th_percentile": 513.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 785.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 785.59, "10th_percentile": 785.59, "90th_percentile": 785.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 785.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 785.59, "10th_percentile": 785.59, "90th_percentile": 785.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 149.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 149.26, "10th_percentile": 149.26, "90th_percentile": 149.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 149.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 149.26, "10th_percentile": 149.26, "90th_percentile": 149.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 439.14, "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": 439.14, "10th_percentile": 439.14, "90th_percentile": 439.14, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 442.68, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.68, "10th_percentile": 442.68, "90th_percentile": 442.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 526.82, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 526.82, "10th_percentile": 526.82, "90th_percentile": 526.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 640.26, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 640.26, "10th_percentile": 640.26, "90th_percentile": 640.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 495.79, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 495.79, "10th_percentile": 495.79, "90th_percentile": 495.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 511.81, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 511.81, "10th_percentile": 511.81, "90th_percentile": 511.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "GUAIFENESIN 600 MG ORAL TA12", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-200446", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "63824-0008-34", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.18, "maximum": 16.75, "setting": "outpatient", "gross_charge": 16.75, "discounted_cash": 11.72, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 3.18, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3.18, "10th_percentile": 3.18, "90th_percentile": 3.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 13.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 13.4, "10th_percentile": 13.4, "90th_percentile": 13.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 8.09, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.09, "10th_percentile": 8.09, "90th_percentile": 8.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 7.59, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.59, "10th_percentile": 7.59, "90th_percentile": 7.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 12.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 12.56, "10th_percentile": 12.56, "90th_percentile": 12.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 7.54, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 10.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10.91, "10th_percentile": 10.91, "90th_percentile": 10.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 14.66, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 14.66, "10th_percentile": 14.66, "90th_percentile": 14.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 11.29, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 11.29, "10th_percentile": 11.29, "90th_percentile": 11.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 13.65, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.65, "10th_percentile": 13.65, "90th_percentile": 13.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 14.24, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 14.24, "10th_percentile": 14.24, "90th_percentile": 14.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 9.1, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 9.1, "10th_percentile": 9.1, "90th_percentile": 9.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 8.41, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.41, "10th_percentile": 8.41, "90th_percentile": 8.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 16.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 11.21, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.21, "10th_percentile": 11.21, "90th_percentile": 11.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 11.61, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.61, "10th_percentile": 11.61, "90th_percentile": 11.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.25, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% 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 Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 5.83, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 5.83, "10th_percentile": 5.83, "90th_percentile": 5.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 10.95, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.95, "10th_percentile": 10.95, "90th_percentile": 10.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 3.18, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 3.18, "10th_percentile": 3.18, "90th_percentile": 3.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3.18, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 3.18, "10th_percentile": 3.18, "90th_percentile": 3.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9.44, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.44, "10th_percentile": 9.44, "90th_percentile": 9.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10.57, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.57, "10th_percentile": 10.57, "90th_percentile": 10.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 10.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10.91, "10th_percentile": 10.91, "90th_percentile": 10.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 13.65, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.65, "10th_percentile": 13.65, "90th_percentile": 13.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11.23, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.23, "10th_percentile": 11.23, "90th_percentile": 11.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9.36, "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": 9.36, "10th_percentile": 9.36, "90th_percentile": 9.36, "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": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "GUIDEWIRE 5.0 W/TROCAR TIP 1.6MM AR-8750K", "code_information": [ { "code": "SUP-338967", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 13.83, "maximum": 200.41, "setting": "outpatient", "gross_charge": 200.41, "discounted_cash": 140.29, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 130.57, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 130.57, "10th_percentile": 130.57, "90th_percentile": 130.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 160.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 160.33, "10th_percentile": 160.33, "90th_percentile": 160.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 135.08, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 135.08, "10th_percentile": 135.08, "90th_percentile": 135.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 90.18, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 90.18, "10th_percentile": 90.18, "90th_percentile": 90.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 163.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 163.73, "10th_percentile": 163.73, "90th_percentile": 163.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 170.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 170.35, "10th_percentile": 170.35, "90th_percentile": 170.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 175.36, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 175.36, "10th_percentile": 175.36, "90th_percentile": 175.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 108.92, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 108.92, "10th_percentile": 108.92, "90th_percentile": 108.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 96.8, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 96.8, "10th_percentile": 96.8, "90th_percentile": 96.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 90.79, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.79, "10th_percentile": 90.79, "90th_percentile": 90.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 150.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 150.31, "10th_percentile": 150.31, "90th_percentile": 150.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 200.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 200.41, "10th_percentile": 200.41, "90th_percentile": 200.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 134.07, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.07, "10th_percentile": 134.07, "90th_percentile": 134.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 100.61, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.61, "10th_percentile": 100.61, "90th_percentile": 100.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 50.9, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 50.9, "10th_percentile": 50.9, "90th_percentile": 50.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 69.74, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 69.74, "10th_percentile": 69.74, "90th_percentile": 69.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 138.88, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.88, "10th_percentile": 138.88, "90th_percentile": 138.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 131.07, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 131.07, "10th_percentile": 131.07, "90th_percentile": 131.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 200.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 200.41, "10th_percentile": 200.41, "90th_percentile": 200.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 200.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 200.41, "10th_percentile": 200.41, "90th_percentile": 200.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 130.57, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 130.57, "10th_percentile": 130.57, "90th_percentile": 130.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 163.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 163.73, "10th_percentile": 163.73, "90th_percentile": 163.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 126.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 126.26, "10th_percentile": 126.26, "90th_percentile": 126.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 112.03, "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": 112.03, "10th_percentile": 112.03, "90th_percentile": 112.03, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 121.05, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.05, "10th_percentile": 121.05, "90th_percentile": 121.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 121.05, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.05, "10th_percentile": 121.05, "90th_percentile": 121.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 38.08, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 38.08, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 38.08, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "GUIDEWIRE SENSOR DUAL FLEX 0.035IN M0066703080", "code_information": [ { "code": "SUP-8023364", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 38.08, "maximum": 551.92, "setting": "outpatient", "gross_charge": 551.92, "discounted_cash": 386.34, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 359.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 359.58, "10th_percentile": 359.58, "90th_percentile": 359.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 441.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 441.54, "10th_percentile": 441.54, "90th_percentile": 441.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 371.99, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 371.99, "10th_percentile": 371.99, "90th_percentile": 371.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 248.36, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 248.36, "10th_percentile": 248.36, "90th_percentile": 248.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 450.92, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 450.92, "10th_percentile": 450.92, "90th_percentile": 450.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 469.13, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 469.13, "10th_percentile": 469.13, "90th_percentile": 469.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 482.93, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 482.93, "10th_percentile": 482.93, "90th_percentile": 482.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 299.97, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 299.97, "10th_percentile": 299.97, "90th_percentile": 299.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 266.58, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 266.58, "10th_percentile": 266.58, "90th_percentile": 266.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 250.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.02, "10th_percentile": 250.02, "90th_percentile": 250.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 413.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 413.94, "10th_percentile": 413.94, "90th_percentile": 413.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 551.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 551.92, "10th_percentile": 551.92, "90th_percentile": 551.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 369.23, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 369.23, "10th_percentile": 369.23, "90th_percentile": 369.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 277.06, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 277.06, "10th_percentile": 277.06, "90th_percentile": 277.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 140.19, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 140.19, "10th_percentile": 140.19, "90th_percentile": 140.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 192.07, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 192.07, "10th_percentile": 192.07, "90th_percentile": 192.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 382.48, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 382.48, "10th_percentile": 382.48, "90th_percentile": 382.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 360.96, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.96, "10th_percentile": 360.96, "90th_percentile": 360.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 551.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 551.92, "10th_percentile": 551.92, "90th_percentile": 551.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 551.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 551.92, "10th_percentile": 551.92, "90th_percentile": 551.92, "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": "VWH BCBS HMO", "standard_charge_dollar": 359.58, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 359.58, "10th_percentile": 359.58, "90th_percentile": 359.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 450.92, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 450.92, "10th_percentile": 450.92, "90th_percentile": 450.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 347.71, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 347.71, "10th_percentile": 347.71, "90th_percentile": 347.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 308.52, "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": 308.52, "10th_percentile": 308.52, "90th_percentile": 308.52, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 333.36, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 333.36, "10th_percentile": 333.36, "90th_percentile": 333.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 333.36, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 333.36, "10th_percentile": 333.36, "90th_percentile": 333.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 104.86, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 104.86, "10th_percentile": 104.86, "90th_percentile": 104.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 104.86, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 104.86, "10th_percentile": 104.86, "90th_percentile": 104.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 104.86, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 104.86, "10th_percentile": 104.86, "90th_percentile": 104.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "GUIDEWIRE SYNTHES 1.1MM THREAD (292.622)", "code_information": [ { "code": "SUP-122054", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 24.46, "maximum": 354.45, "setting": "outpatient", "gross_charge": 354.45, "discounted_cash": 248.11, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 230.92, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 230.92, "10th_percentile": 230.92, "90th_percentile": 230.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 283.56, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 283.56, "10th_percentile": 283.56, "90th_percentile": 283.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 238.9, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 238.9, "10th_percentile": 238.9, "90th_percentile": 238.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 159.5, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 159.5, "10th_percentile": 159.5, "90th_percentile": 159.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 289.59, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 289.59, "10th_percentile": 289.59, "90th_percentile": 289.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 301.28, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 301.28, "10th_percentile": 301.28, "90th_percentile": 301.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 310.14, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 310.14, "10th_percentile": 310.14, "90th_percentile": 310.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 192.64, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 192.64, "10th_percentile": 192.64, "90th_percentile": 192.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 171.2, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 171.2, "10th_percentile": 171.2, "90th_percentile": 171.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 160.57, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.57, "10th_percentile": 160.57, "90th_percentile": 160.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 265.84, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 265.84, "10th_percentile": 265.84, "90th_percentile": 265.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 354.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 354.45, "10th_percentile": 354.45, "90th_percentile": 354.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 237.13, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 237.13, "10th_percentile": 237.13, "90th_percentile": 237.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 177.93, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.93, "10th_percentile": 177.93, "90th_percentile": 177.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 90.03, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 90.03, "10th_percentile": 90.03, "90th_percentile": 90.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 123.35, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 123.35, "10th_percentile": 123.35, "90th_percentile": 123.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 245.63, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.63, "10th_percentile": 245.63, "90th_percentile": 245.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 231.81, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 231.81, "10th_percentile": 231.81, "90th_percentile": 231.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.45, "10th_percentile": 354.45, "90th_percentile": 354.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.45, "10th_percentile": 354.45, "90th_percentile": 354.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 230.92, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 230.92, "10th_percentile": 230.92, "90th_percentile": 230.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 289.59, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 289.59, "10th_percentile": 289.59, "90th_percentile": 289.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 223.3, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 223.3, "10th_percentile": 223.3, "90th_percentile": 223.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 198.14, "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": 198.14, "10th_percentile": 198.14, "90th_percentile": 198.14, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 214.09, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 214.09, "10th_percentile": 214.09, "90th_percentile": 214.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 214.09, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 214.09, "10th_percentile": 214.09, "90th_percentile": 214.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 67.35, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 67.35, "10th_percentile": 67.35, "90th_percentile": 67.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 67.35, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 67.35, "10th_percentile": 67.35, "90th_percentile": 67.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 67.35, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 67.35, "10th_percentile": 67.35, "90th_percentile": 67.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 24.46, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 24.46, "10th_percentile": 24.46, "90th_percentile": 24.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 24.46, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 24.46, "10th_percentile": 24.46, "90th_percentile": 24.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 24.46, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 24.46, "10th_percentile": 24.46, "90th_percentile": 24.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 24.46, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 24.46, "10th_percentile": 24.46, "90th_percentile": 24.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 24.46, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 24.46, "10th_percentile": 24.46, "90th_percentile": 24.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 24.46, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 24.46, "10th_percentile": 24.46, "90th_percentile": 24.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "GUIDEWIRE SYNTHES 2.5MM 310.243", "code_information": [ { "code": "SUP-58390", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 38.92, "maximum": 564.01, "setting": "outpatient", "gross_charge": 564.01, "discounted_cash": 394.81, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 367.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 367.45, "10th_percentile": 367.45, "90th_percentile": 367.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 451.21, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 451.21, "10th_percentile": 451.21, "90th_percentile": 451.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 380.14, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 380.14, "10th_percentile": 380.14, "90th_percentile": 380.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 253.8, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 253.8, "10th_percentile": 253.8, "90th_percentile": 253.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 460.8, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 460.8, "10th_percentile": 460.8, "90th_percentile": 460.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 479.41, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 479.41, "10th_percentile": 479.41, "90th_percentile": 479.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 493.51, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 493.51, "10th_percentile": 493.51, "90th_percentile": 493.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 306.54, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 306.54, "10th_percentile": 306.54, "90th_percentile": 306.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 272.42, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 272.42, "10th_percentile": 272.42, "90th_percentile": 272.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 255.5, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 255.5, "10th_percentile": 255.5, "90th_percentile": 255.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 423.01, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 423.01, "10th_percentile": 423.01, "90th_percentile": 423.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 564.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 564.01, "10th_percentile": 564.01, "90th_percentile": 564.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 377.32, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 377.32, "10th_percentile": 377.32, "90th_percentile": 377.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 283.13, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 283.13, "10th_percentile": 283.13, "90th_percentile": 283.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 143.26, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 143.26, "10th_percentile": 143.26, "90th_percentile": 143.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 196.28, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 196.28, "10th_percentile": 196.28, "90th_percentile": 196.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 390.86, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 390.86, "10th_percentile": 390.86, "90th_percentile": 390.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 368.86, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 368.86, "10th_percentile": 368.86, "90th_percentile": 368.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 564.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 564.01, "10th_percentile": 564.01, "90th_percentile": 564.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 564.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 564.01, "10th_percentile": 564.01, "90th_percentile": 564.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 367.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 367.45, "10th_percentile": 367.45, "90th_percentile": 367.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 460.8, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 460.8, "10th_percentile": 460.8, "90th_percentile": 460.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 355.33, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 355.33, "10th_percentile": 355.33, "90th_percentile": 355.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 315.28, "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": 315.28, "10th_percentile": 315.28, "90th_percentile": 315.28, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 340.66, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 340.66, "10th_percentile": 340.66, "90th_percentile": 340.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 340.66, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 340.66, "10th_percentile": 340.66, "90th_percentile": 340.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 107.16, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 107.16, "10th_percentile": 107.16, "90th_percentile": 107.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 107.16, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 107.16, "10th_percentile": 107.16, "90th_percentile": 107.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 107.16, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 107.16, "10th_percentile": 107.16, "90th_percentile": 107.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.92, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.92, "10th_percentile": 38.92, "90th_percentile": 38.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.92, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.92, "10th_percentile": 38.92, "90th_percentile": 38.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.92, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.92, "10th_percentile": 38.92, "90th_percentile": 38.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.92, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.92, "10th_percentile": 38.92, "90th_percentile": 38.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.92, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.92, "10th_percentile": 38.92, "90th_percentile": 38.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 38.92, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 38.92, "10th_percentile": 38.92, "90th_percentile": 38.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "GW ZIPWIRE STIFF .038INX150CM", "code_information": [ { "code": "SUP-317225", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 139.46, "maximum": 734.02, "setting": "outpatient", "gross_charge": 734.02, "discounted_cash": 513.81, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 734.02, "10th_percentile": 734.02, "90th_percentile": 734.02, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 734.02, "10th_percentile": 734.02, "90th_percentile": 734.02, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 734.02, "10th_percentile": 734.02, "90th_percentile": 734.02, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 734.02, "10th_percentile": 734.02, "90th_percentile": 734.02, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 734.02, "10th_percentile": 734.02, "90th_percentile": 734.02, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 734.02, "10th_percentile": 734.02, "90th_percentile": 734.02, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 139.46, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 139.46, "10th_percentile": 139.46, "90th_percentile": 139.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 642.27, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 642.27, "10th_percentile": 642.27, "90th_percentile": 642.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 494.73, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 494.73, "10th_percentile": 494.73, "90th_percentile": 494.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 598.23, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 598.23, "10th_percentile": 598.23, "90th_percentile": 598.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 332.51, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 332.51, "10th_percentile": 332.51, "90th_percentile": 332.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 330.31, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 330.31, "10th_percentile": 330.31, "90th_percentile": 330.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 623.92, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 623.92, "10th_percentile": 623.92, "90th_percentile": 623.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 354.53, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 354.53, "10th_percentile": 354.53, "90th_percentile": 354.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 478.21, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 478.21, "10th_percentile": 478.21, "90th_percentile": 478.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 587.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 587.22, "10th_percentile": 587.22, "90th_percentile": 587.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 398.94, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 398.94, "10th_percentile": 398.94, "90th_percentile": 398.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 550.52, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 550.52, "10th_percentile": 550.52, "90th_percentile": 550.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 734.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 734.02, "10th_percentile": 734.02, "90th_percentile": 734.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 491.06, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 491.06, "10th_percentile": 491.06, "90th_percentile": 491.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 368.48, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 368.48, "10th_percentile": 368.48, "90th_percentile": 368.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 186.44, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 186.44, "10th_percentile": 186.44, "90th_percentile": 186.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 508.68, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 508.68, "10th_percentile": 508.68, "90th_percentile": 508.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 255.44, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 255.44, "10th_percentile": 255.44, "90th_percentile": 255.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 480.05, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 480.05, "10th_percentile": 480.05, "90th_percentile": 480.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 734.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 734.02, "10th_percentile": 734.02, "90th_percentile": 734.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 734.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 734.02, "10th_percentile": 734.02, "90th_percentile": 734.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 139.46, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 139.46, "10th_percentile": 139.46, "90th_percentile": 139.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 139.46, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 139.46, "10th_percentile": 139.46, "90th_percentile": 139.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 410.32, "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": 410.32, "10th_percentile": 410.32, "90th_percentile": 410.32, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 413.62, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 413.62, "10th_percentile": 413.62, "90th_percentile": 413.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 492.23, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 492.23, "10th_percentile": 492.23, "90th_percentile": 492.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 598.23, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 598.23, "10th_percentile": 598.23, "90th_percentile": 598.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 463.24, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 463.24, "10th_percentile": 463.24, "90th_percentile": 463.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 478.21, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 478.21, "10th_percentile": 478.21, "90th_percentile": 478.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "GWIRE TRCR 0.86MM W/LSR LN", "code_information": [ { "code": "SUP-137861", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 13.83, "maximum": 200.41, "setting": "outpatient", "gross_charge": 200.41, "discounted_cash": 140.29, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 130.57, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 130.57, "10th_percentile": 130.57, "90th_percentile": 130.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 160.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 160.33, "10th_percentile": 160.33, "90th_percentile": 160.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 135.08, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 135.08, "10th_percentile": 135.08, "90th_percentile": 135.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 90.18, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 90.18, "10th_percentile": 90.18, "90th_percentile": 90.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 163.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 163.73, "10th_percentile": 163.73, "90th_percentile": 163.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 170.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 170.35, "10th_percentile": 170.35, "90th_percentile": 170.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 175.36, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 175.36, "10th_percentile": 175.36, "90th_percentile": 175.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 108.92, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 108.92, "10th_percentile": 108.92, "90th_percentile": 108.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 96.8, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 96.8, "10th_percentile": 96.8, "90th_percentile": 96.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 90.79, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.79, "10th_percentile": 90.79, "90th_percentile": 90.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 150.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 150.31, "10th_percentile": 150.31, "90th_percentile": 150.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 200.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 200.41, "10th_percentile": 200.41, "90th_percentile": 200.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 134.07, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.07, "10th_percentile": 134.07, "90th_percentile": 134.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 100.61, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.61, "10th_percentile": 100.61, "90th_percentile": 100.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 50.9, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 50.9, "10th_percentile": 50.9, "90th_percentile": 50.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 69.74, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 69.74, "10th_percentile": 69.74, "90th_percentile": 69.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 138.88, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.88, "10th_percentile": 138.88, "90th_percentile": 138.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 131.07, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 131.07, "10th_percentile": 131.07, "90th_percentile": 131.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 200.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 200.41, "10th_percentile": 200.41, "90th_percentile": 200.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 200.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 200.41, "10th_percentile": 200.41, "90th_percentile": 200.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 130.57, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 130.57, "10th_percentile": 130.57, "90th_percentile": 130.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 163.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 163.73, "10th_percentile": 163.73, "90th_percentile": 163.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 126.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 126.26, "10th_percentile": 126.26, "90th_percentile": 126.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 112.03, "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": 112.03, "10th_percentile": 112.03, "90th_percentile": 112.03, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 121.05, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.05, "10th_percentile": 121.05, "90th_percentile": 121.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 121.05, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.05, "10th_percentile": 121.05, "90th_percentile": 121.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 38.08, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 38.08, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 38.08, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 38.08, "10th_percentile": 38.08, "90th_percentile": 38.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 13.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HARMONIC ACE + SHEARS 36CM (HAR36)", "code_information": [ { "code": "SUP-149871", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 689.36, "maximum": 3628.2, "setting": "outpatient", "gross_charge": 3628.2, "discounted_cash": 2539.74, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3628.2, "10th_percentile": 3628.2, "90th_percentile": 3628.2, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3628.2, "10th_percentile": 3628.2, "90th_percentile": 3628.2, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3628.2, "10th_percentile": 3628.2, "90th_percentile": 3628.2, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3628.2, "10th_percentile": 3628.2, "90th_percentile": 3628.2, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3628.2, "10th_percentile": 3628.2, "90th_percentile": 3628.2, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3628.2, "10th_percentile": 3628.2, "90th_percentile": 3628.2, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 689.36, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 689.36, "10th_percentile": 689.36, "90th_percentile": 689.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 3174.68, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 3174.68, "10th_percentile": 3174.68, "90th_percentile": 3174.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2445.41, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2445.41, "10th_percentile": 2445.41, "90th_percentile": 2445.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2956.98, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2956.98, "10th_percentile": 2956.98, "90th_percentile": 2956.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1643.57, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1643.57, "10th_percentile": 1643.57, "90th_percentile": 1643.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1632.69, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1632.69, "10th_percentile": 1632.69, "90th_percentile": 1632.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 3083.97, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 3083.97, "10th_percentile": 3083.97, "90th_percentile": 3083.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1752.42, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1752.42, "10th_percentile": 1752.42, "90th_percentile": 1752.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2363.77, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2363.77, "10th_percentile": 2363.77, "90th_percentile": 2363.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2902.56, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2902.56, "10th_percentile": 2902.56, "90th_percentile": 2902.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1971.93, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1971.93, "10th_percentile": 1971.93, "90th_percentile": 1971.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2721.15, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2721.15, "10th_percentile": 2721.15, "90th_percentile": 2721.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3628.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3628.2, "10th_percentile": 3628.2, "90th_percentile": 3628.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2427.27, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2427.27, "10th_percentile": 2427.27, "90th_percentile": 2427.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1821.36, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1821.36, "10th_percentile": 1821.36, "90th_percentile": 1821.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 921.56, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 921.56, "10th_percentile": 921.56, "90th_percentile": 921.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2514.34, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2514.34, "10th_percentile": 2514.34, "90th_percentile": 2514.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1262.61, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1262.61, "10th_percentile": 1262.61, "90th_percentile": 1262.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2372.84, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2372.84, "10th_percentile": 2372.84, "90th_percentile": 2372.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3628.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3628.2, "10th_percentile": 3628.2, "90th_percentile": 3628.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3628.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3628.2, "10th_percentile": 3628.2, "90th_percentile": 3628.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 689.36, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 689.36, "10th_percentile": 689.36, "90th_percentile": 689.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 689.36, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 689.36, "10th_percentile": 689.36, "90th_percentile": 689.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2028.16, "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": 2028.16, "10th_percentile": 2028.16, "90th_percentile": 2028.16, "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": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2044.49, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2044.49, "10th_percentile": 2044.49, "90th_percentile": 2044.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2433.07, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2433.07, "10th_percentile": 2433.07, "90th_percentile": 2433.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2956.98, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2956.98, "10th_percentile": 2956.98, "90th_percentile": 2956.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2289.76, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2289.76, "10th_percentile": 2289.76, "90th_percentile": 2289.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2363.77, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2363.77, "10th_percentile": 2363.77, "90th_percentile": 2363.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB 9vhpv Vacc 2/3 Dose Sched Im Use", "code_information": [ { "code": "PX-63600155", "type": "CDM" }, { "code": "90651", "type": "CPT" }, { "code": "0636", "type": "RC" } ], "standard_charges": [ { "minimum": 114.95, "maximum": 605.0, "setting": "outpatient", "gross_charge": 605.0, "discounted_cash": 423.5, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 365.42, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 365.42, "10th_percentile": 365.42, "90th_percentile": 365.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 365.42, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 365.42, "10th_percentile": 365.42, "90th_percentile": 365.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 394.16, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 394.16, "10th_percentile": 394.16, "90th_percentile": 394.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 338.2, "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": 338.2, "10th_percentile": 338.2, "90th_percentile": 338.2, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 381.15, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381.15, "10th_percentile": 381.15, "90th_percentile": 381.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 494.29, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 494.29, "10th_percentile": 494.29, "90th_percentile": 494.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 114.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 114.95, "10th_percentile": 114.95, "90th_percentile": 114.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 114.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 114.95, "10th_percentile": 114.95, "90th_percentile": 114.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 114.95, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 114.95, "10th_percentile": 114.95, "90th_percentile": 114.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 605.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 605.0, "10th_percentile": 605.0, "90th_percentile": 605.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 605.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 605.0, "10th_percentile": 605.0, "90th_percentile": 605.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 395.67, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 395.67, "10th_percentile": 395.67, "90th_percentile": 395.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 153.67, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 153.67, "10th_percentile": 153.67, "90th_percentile": 153.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 419.27, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 419.27, "10th_percentile": 419.27, "90th_percentile": 419.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 210.54, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 210.54, "10th_percentile": 210.54, "90th_percentile": 210.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 605.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 605.0, "10th_percentile": 605.0, "90th_percentile": 605.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 529.38, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 529.38, "10th_percentile": 529.38, "90th_percentile": 529.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 394.16, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 394.16, "10th_percentile": 394.16, "90th_percentile": 394.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 328.82, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 328.82, "10th_percentile": 328.82, "90th_percentile": 328.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 407.77, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 407.77, "10th_percentile": 407.77, "90th_percentile": 407.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 453.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 453.75, "10th_percentile": 453.75, "90th_percentile": 453.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 514.25, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 514.25, "10th_percentile": 514.25, "90th_percentile": 514.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 272.25, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 272.25, "10th_percentile": 272.25, "90th_percentile": 272.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 484.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 484.0, "10th_percentile": 484.0, "90th_percentile": 484.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 494.29, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 494.29, "10th_percentile": 494.29, "90th_percentile": 494.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Ablate Arrhythmia Add On", "code_information": [ { "code": "PX-48100102", "type": "CDM" }, { "code": "93655", "type": "CPT" }, { "code": "0481", "type": "RC" } ], "standard_charges": [ { "minimum": 12634.84, "maximum": 25169.0, "setting": "outpatient", "gross_charge": 25169.0, "discounted_cash": 17618.3, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 25169.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 25169.0, "10th_percentile": 25169.0, "90th_percentile": 25169.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 16838.06, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16838.06, "10th_percentile": 16838.06, "90th_percentile": 16838.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 12634.84, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12634.84, "10th_percentile": 12634.84, "90th_percentile": 12634.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Abo Anti-B Igg Titer", "code_information": [ { "code": "PX-30208680", "type": "CDM" }, { "code": "86886", "type": "CPT" }, { "code": "0302", "type": "RC" } ], "standard_charges": [ { "minimum": 47.88, "maximum": 252.0, "setting": "outpatient", "gross_charge": 252.0, "discounted_cash": 176.4, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 252.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 252.0, "10th_percentile": 252.0, "90th_percentile": 252.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 252.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 252.0, "10th_percentile": 252.0, "90th_percentile": 252.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 205.88, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.88, "10th_percentile": 205.88, "90th_percentile": 205.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 220.5, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 220.5, "10th_percentile": 220.5, "90th_percentile": 220.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 214.2, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 214.2, "10th_percentile": 214.2, "90th_percentile": 214.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 164.18, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 164.18, "10th_percentile": 164.18, "90th_percentile": 164.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 252.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 252.0, "10th_percentile": 252.0, "90th_percentile": 252.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 189.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 189.0, "10th_percentile": 189.0, "90th_percentile": 189.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 169.85, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 169.85, "10th_percentile": 169.85, "90th_percentile": 169.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 201.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 201.6, "10th_percentile": 201.6, "90th_percentile": 201.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 136.96, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 136.96, "10th_percentile": 136.96, "90th_percentile": 136.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 113.4, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 113.4, "10th_percentile": 113.4, "90th_percentile": 113.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 174.64, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.64, "10th_percentile": 174.64, "90th_percentile": 174.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 87.7, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 87.7, "10th_percentile": 87.7, "90th_percentile": 87.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 64.01, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 64.01, "10th_percentile": 64.01, "90th_percentile": 64.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 205.88, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.88, "10th_percentile": 205.88, "90th_percentile": 205.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 158.76, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.76, "10th_percentile": 158.76, "90th_percentile": 158.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 140.87, "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": 140.87, "10th_percentile": 140.87, "90th_percentile": 140.87, "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": "VWH BCBS HMO", "standard_charge_dollar": 164.18, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 164.18, "10th_percentile": 164.18, "90th_percentile": 164.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 152.21, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.21, "10th_percentile": 152.21, "90th_percentile": 152.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 152.21, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.21, "10th_percentile": 152.21, "90th_percentile": 152.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 47.88, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 47.88, "10th_percentile": 47.88, "90th_percentile": 47.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 47.88, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 47.88, "10th_percentile": 47.88, "90th_percentile": 47.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 47.88, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 47.88, "10th_percentile": 47.88, "90th_percentile": 47.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Adrenocordicotropic Hormone", "code_information": [ { "code": "PX-30105020", "type": "CDM" }, { "code": "82024", "type": "CPT" }, { "code": "0301", "type": "RC" } ], "standard_charges": [ { "minimum": 73.34, "maximum": 386.0, "setting": "outpatient", "gross_charge": 386.0, "discounted_cash": 270.2, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 233.14, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 233.14, "10th_percentile": 233.14, "90th_percentile": 233.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 233.14, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 233.14, "10th_percentile": 233.14, "90th_percentile": 233.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 251.48, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 251.48, "10th_percentile": 251.48, "90th_percentile": 251.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 215.77, "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": 215.77, "10th_percentile": 215.77, "90th_percentile": 215.77, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 243.18, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.18, "10th_percentile": 243.18, "90th_percentile": 243.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 315.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 315.36, "10th_percentile": 315.36, "90th_percentile": 315.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 328.1, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 328.1, "10th_percentile": 328.1, "90th_percentile": 328.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 386.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 386.0, "10th_percentile": 386.0, "90th_percentile": 386.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 308.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 308.8, "10th_percentile": 308.8, "90th_percentile": 308.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 173.7, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 173.7, "10th_percentile": 173.7, "90th_percentile": 173.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 260.16, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 260.16, "10th_percentile": 260.16, "90th_percentile": 260.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 289.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 289.5, "10th_percentile": 289.5, "90th_percentile": 289.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 337.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 337.75, "10th_percentile": 337.75, "90th_percentile": 337.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 209.79, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 209.79, "10th_percentile": 209.79, "90th_percentile": 209.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 251.48, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 251.48, "10th_percentile": 251.48, "90th_percentile": 251.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 315.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 315.36, "10th_percentile": 315.36, "90th_percentile": 315.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 98.04, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 98.04, "10th_percentile": 98.04, "90th_percentile": 98.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 134.33, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 134.33, "10th_percentile": 134.33, "90th_percentile": 134.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 267.5, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 267.5, "10th_percentile": 267.5, "90th_percentile": 267.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 386.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 386.0, "10th_percentile": 386.0, "90th_percentile": 386.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 386.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 386.0, "10th_percentile": 386.0, "90th_percentile": 386.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 73.34, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 73.34, "10th_percentile": 73.34, "90th_percentile": 73.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 73.34, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 73.34, "10th_percentile": 73.34, "90th_percentile": 73.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 73.34, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 73.34, "10th_percentile": 73.34, "90th_percentile": 73.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Als1-Emergency", "code_information": [ { "code": "PX-54000002", "type": "CDM" }, { "code": "A0427", "type": "HCPCS" }, { "code": "0540", "type": "RC" } ], "standard_charges": [ { "minimum": 222.11, "maximum": 3219.0, "setting": "outpatient", "gross_charge": 3219.0, "discounted_cash": 2253.3, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2816.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2816.63, "10th_percentile": 2816.63, "90th_percentile": 2816.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1448.55, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1448.55, "10th_percentile": 1448.55, "90th_percentile": 1448.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2736.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2736.15, "10th_percentile": 2736.15, "90th_percentile": 2736.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1749.53, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1749.53, "10th_percentile": 1749.53, "90th_percentile": 1749.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2414.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2414.25, "10th_percentile": 2414.25, "90th_percentile": 2414.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2169.61, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2169.61, "10th_percentile": 2169.61, "90th_percentile": 2169.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2097.18, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2097.18, "10th_percentile": 2097.18, "90th_percentile": 2097.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3219.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3219.0, "10th_percentile": 3219.0, "90th_percentile": 3219.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2575.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2575.2, "10th_percentile": 2575.2, "90th_percentile": 2575.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 611.61, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 611.61, "10th_percentile": 611.61, "90th_percentile": 611.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 611.61, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 611.61, "10th_percentile": 611.61, "90th_percentile": 611.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2153.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2153.51, "10th_percentile": 2153.51, "90th_percentile": 2153.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1615.94, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1615.94, "10th_percentile": 1615.94, "90th_percentile": 1615.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1458.21, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1458.21, "10th_percentile": 1458.21, "90th_percentile": 1458.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1554.78, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1554.78, "10th_percentile": 1554.78, "90th_percentile": 1554.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2105.23, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2105.23, "10th_percentile": 2105.23, "90th_percentile": 2105.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2230.77, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2230.77, "10th_percentile": 2230.77, "90th_percentile": 2230.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 817.63, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 817.63, "10th_percentile": 817.63, "90th_percentile": 817.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1120.21, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1120.21, "10th_percentile": 1120.21, "90th_percentile": 1120.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3219.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3219.0, "10th_percentile": 3219.0, "90th_percentile": 3219.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3219.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3219.0, "10th_percentile": 3219.0, "90th_percentile": 3219.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 611.61, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 611.61, "10th_percentile": 611.61, "90th_percentile": 611.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1799.42, "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": 1799.42, "10th_percentile": 1799.42, "90th_percentile": 1799.42, "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": "VWH BCBS HMO", "standard_charge_dollar": 2097.18, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2097.18, "10th_percentile": 2097.18, "90th_percentile": 2097.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 222.11, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 222.11, "10th_percentile": 222.11, "90th_percentile": 222.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 222.11, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 222.11, "10th_percentile": 222.11, "90th_percentile": 222.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 222.11, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 222.11, "10th_percentile": 222.11, "90th_percentile": 222.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 222.11, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 222.11, "10th_percentile": 222.11, "90th_percentile": 222.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 222.11, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 222.11, "10th_percentile": 222.11, "90th_percentile": 222.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 222.11, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 222.11, "10th_percentile": 222.11, "90th_percentile": 222.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx", "code_information": [ { "code": "PX-76100405", "type": "CDM" }, { "code": "46607", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 1014.03, "maximum": 5337.0, "setting": "outpatient", "gross_charge": 5337.0, "discounted_cash": 3735.9, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3362.31, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3362.31, "10th_percentile": 3362.31, "90th_percentile": 3362.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4360.33, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4360.33, "10th_percentile": 4360.33, "90th_percentile": 4360.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3223.55, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3223.55, "10th_percentile": 3223.55, "90th_percentile": 3223.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3223.55, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3223.55, "10th_percentile": 3223.55, "90th_percentile": 3223.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2983.38, "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": 2983.38, "10th_percentile": 2983.38, "90th_percentile": 2983.38, "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4360.33, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4360.33, "10th_percentile": 4360.33, "90th_percentile": 4360.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2417.66, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2417.66, "10th_percentile": 2417.66, "90th_percentile": 2417.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2577.77, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2577.77, "10th_percentile": 2577.77, "90th_percentile": 2577.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 4536.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4536.45, "10th_percentile": 4536.45, "90th_percentile": 4536.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4002.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4002.75, "10th_percentile": 4002.75, "90th_percentile": 4002.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2900.66, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2900.66, "10th_percentile": 2900.66, "90th_percentile": 2900.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3597.14, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3597.14, "10th_percentile": 3597.14, "90th_percentile": 3597.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4669.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4669.88, "10th_percentile": 4669.88, "90th_percentile": 4669.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4269.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 4269.6, "10th_percentile": 4269.6, "90th_percentile": 4269.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2401.65, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2401.65, "10th_percentile": 2401.65, "90th_percentile": 2401.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1355.6, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1355.6, "10th_percentile": 1355.6, "90th_percentile": 1355.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1857.28, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1857.28, "10th_percentile": 1857.28, "90th_percentile": 1857.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3698.54, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3698.54, "10th_percentile": 3698.54, "90th_percentile": 3698.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3490.4, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3490.4, "10th_percentile": 3490.4, "90th_percentile": 3490.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 1014.03, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1014.03, "10th_percentile": 1014.03, "90th_percentile": 1014.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1014.03, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1014.03, "10th_percentile": 1014.03, "90th_percentile": 1014.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1014.03, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1014.03, "10th_percentile": 1014.03, "90th_percentile": 1014.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5337.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5337.0, "10th_percentile": 5337.0, "90th_percentile": 5337.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5337.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5337.0, "10th_percentile": 5337.0, "90th_percentile": 5337.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 3477.06, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3477.06, "10th_percentile": 3477.06, "90th_percentile": 3477.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3477.06, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3477.06, "10th_percentile": 3477.06, "90th_percentile": 3477.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Antimicrobial Dressing", "code_information": [ { "code": "PX-27205001", "type": "CDM" }, { "code": "27205001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 114.19, "maximum": 601.0, "setting": "outpatient", "gross_charge": 601.0, "discounted_cash": 420.7, "payers_information": [ { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 601.0, "10th_percentile": 601.0, "90th_percentile": 601.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 601.0, "10th_percentile": 601.0, "90th_percentile": 601.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 601.0, "10th_percentile": 601.0, "90th_percentile": 601.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 601.0, "10th_percentile": 601.0, "90th_percentile": 601.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 601.0, "10th_percentile": 601.0, "90th_percentile": 601.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 601.0, "10th_percentile": 601.0, "90th_percentile": 601.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 326.64, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 326.64, "10th_percentile": 326.64, "90th_percentile": 326.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 480.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 480.8, "10th_percentile": 480.8, "90th_percentile": 480.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 525.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 525.88, "10th_percentile": 525.88, "90th_percentile": 525.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 450.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 450.75, "10th_percentile": 450.75, "90th_percentile": 450.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 270.45, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 270.45, "10th_percentile": 270.45, "90th_percentile": 270.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 510.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 510.85, "10th_percentile": 510.85, "90th_percentile": 510.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 290.28, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 290.28, "10th_percentile": 290.28, "90th_percentile": 290.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 272.25, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 272.25, "10th_percentile": 272.25, "90th_percentile": 272.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 405.07, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 405.07, "10th_percentile": 405.07, "90th_percentile": 405.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 489.82, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 489.82, "10th_percentile": 489.82, "90th_percentile": 489.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 391.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 391.55, "10th_percentile": 391.55, "90th_percentile": 391.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 114.19, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 114.19, "10th_percentile": 114.19, "90th_percentile": 114.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 601.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 601.0, "10th_percentile": 601.0, "90th_percentile": 601.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 402.07, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 402.07, "10th_percentile": 402.07, "90th_percentile": 402.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 301.7, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 301.7, "10th_percentile": 301.7, "90th_percentile": 301.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 152.65, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 152.65, "10th_percentile": 152.65, "90th_percentile": 152.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 209.15, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 209.15, "10th_percentile": 209.15, "90th_percentile": 209.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 416.49, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 416.49, "10th_percentile": 416.49, "90th_percentile": 416.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 393.05, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 393.05, "10th_percentile": 393.05, "90th_percentile": 393.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 601.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 601.0, "10th_percentile": 601.0, "90th_percentile": 601.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 601.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 601.0, "10th_percentile": 601.0, "90th_percentile": 601.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 114.19, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 114.19, "10th_percentile": 114.19, "90th_percentile": 114.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 114.19, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 114.19, "10th_percentile": 114.19, "90th_percentile": 114.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 489.82, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 489.82, "10th_percentile": 489.82, "90th_percentile": 489.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 335.96, "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": 335.96, "10th_percentile": 335.96, "90th_percentile": 335.96, "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": "VWH BCBS HMO", "standard_charge_dollar": 391.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 391.55, "10th_percentile": 391.55, "90th_percentile": 391.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 338.66, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 338.66, "10th_percentile": 338.66, "90th_percentile": 338.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 379.29, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 379.29, "10th_percentile": 379.29, "90th_percentile": 379.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 403.03, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 403.03, "10th_percentile": 403.03, "90th_percentile": 403.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Apheresis Plasma", "code_information": [ { "code": "PX-94000003", "type": "CDM" }, { "code": "36514", "type": "CPT" }, { "code": "0940", "type": "RC" } ], "standard_charges": [ { "minimum": 523.78, "maximum": 7591.0, "setting": "outpatient", "gross_charge": 7591.0, "discounted_cash": 5313.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4584.96, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4584.96, "10th_percentile": 4584.96, "90th_percentile": 4584.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4584.96, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4584.96, "10th_percentile": 4584.96, "90th_percentile": 4584.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 4945.54, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4945.54, "10th_percentile": 4945.54, "90th_percentile": 4945.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4243.37, "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": 4243.37, "10th_percentile": 4243.37, "90th_percentile": 4243.37, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4782.33, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4782.33, "10th_percentile": 4782.33, "90th_percentile": 4782.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 6201.85, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6201.85, "10th_percentile": 6201.85, "90th_percentile": 6201.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1442.29, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1442.29, "10th_percentile": 1442.29, "90th_percentile": 1442.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1442.29, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1442.29, "10th_percentile": 1442.29, "90th_percentile": 1442.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1442.29, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1442.29, "10th_percentile": 1442.29, "90th_percentile": 1442.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7591.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7591.0, "10th_percentile": 7591.0, "90th_percentile": 7591.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7591.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7591.0, "10th_percentile": 7591.0, "90th_percentile": 7591.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 4964.51, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4964.51, "10th_percentile": 4964.51, "90th_percentile": 4964.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1928.11, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1928.11, "10th_percentile": 1928.11, "90th_percentile": 1928.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 5260.56, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5260.56, "10th_percentile": 5260.56, "90th_percentile": 5260.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2641.67, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2641.67, "10th_percentile": 2641.67, "90th_percentile": 2641.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7591.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7591.0, "10th_percentile": 7591.0, "90th_percentile": 7591.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 6642.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 6642.13, "10th_percentile": 6642.13, "90th_percentile": 6642.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 4945.54, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4945.54, "10th_percentile": 4945.54, "90th_percentile": 4945.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 4125.71, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 4125.71, "10th_percentile": 4125.71, "90th_percentile": 4125.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 5116.33, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 5116.33, "10th_percentile": 5116.33, "90th_percentile": 5116.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 5693.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 5693.25, "10th_percentile": 5693.25, "90th_percentile": 5693.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 6452.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 6452.35, "10th_percentile": 6452.35, "90th_percentile": 6452.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 3415.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 3415.95, "10th_percentile": 3415.95, "90th_percentile": 3415.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 6072.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 6072.8, "10th_percentile": 6072.8, "90th_percentile": 6072.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 523.78, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 523.78, "10th_percentile": 523.78, "90th_percentile": 523.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 523.78, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 523.78, "10th_percentile": 523.78, "90th_percentile": 523.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 523.78, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 523.78, "10th_percentile": 523.78, "90th_percentile": 523.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 523.78, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 523.78, "10th_percentile": 523.78, "90th_percentile": 523.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 523.78, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 523.78, "10th_percentile": 523.78, "90th_percentile": 523.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 523.78, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 523.78, "10th_percentile": 523.78, "90th_percentile": 523.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 6201.85, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6201.85, "10th_percentile": 6201.85, "90th_percentile": 6201.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 3810.68, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3810.68, "10th_percentile": 3810.68, "90th_percentile": 3810.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 5078.38, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5078.38, "10th_percentile": 5078.38, "90th_percentile": 5078.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 3666.45, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3666.45, "10th_percentile": 3666.45, "90th_percentile": 3666.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 3438.72, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3438.72, "10th_percentile": 3438.72, "90th_percentile": 3438.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Artery X-Rays Chest", "code_information": [ { "code": "PX-32300012", "type": "CDM" }, { "code": "75756", "type": "CPT" }, { "code": "0323", "type": "RC" } ], "standard_charges": [ { "minimum": 539.6, "maximum": 2840.0, "setting": "outpatient", "gross_charge": 2840.0, "discounted_cash": 1988.0, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1715.36, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1715.36, "10th_percentile": 1715.36, "90th_percentile": 1715.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1715.36, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1715.36, "10th_percentile": 1715.36, "90th_percentile": 1715.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1850.26, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1850.26, "10th_percentile": 1850.26, "90th_percentile": 1850.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1587.56, "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": 1587.56, "10th_percentile": 1587.56, "90th_percentile": 1587.56, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1789.2, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1789.2, "10th_percentile": 1789.2, "90th_percentile": 1789.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2320.28, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2320.28, "10th_percentile": 2320.28, "90th_percentile": 2320.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 539.6, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 539.6, "10th_percentile": 539.6, "90th_percentile": 539.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 539.6, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 539.6, "10th_percentile": 539.6, "90th_percentile": 539.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 539.6, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 539.6, "10th_percentile": 539.6, "90th_percentile": 539.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2840.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2840.0, "10th_percentile": 2840.0, "90th_percentile": 2840.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2840.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2840.0, "10th_percentile": 2840.0, "90th_percentile": 2840.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1857.36, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1857.36, "10th_percentile": 1857.36, "90th_percentile": 1857.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 721.36, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 721.36, "10th_percentile": 721.36, "90th_percentile": 721.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1968.12, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1968.12, "10th_percentile": 1968.12, "90th_percentile": 1968.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 988.32, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 988.32, "10th_percentile": 988.32, "90th_percentile": 988.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2840.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2840.0, "10th_percentile": 2840.0, "90th_percentile": 2840.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2485.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2485.0, "10th_percentile": 2485.0, "90th_percentile": 2485.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1850.26, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1850.26, "10th_percentile": 1850.26, "90th_percentile": 1850.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1543.54, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1543.54, "10th_percentile": 1543.54, "90th_percentile": 1543.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1914.16, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1914.16, "10th_percentile": 1914.16, "90th_percentile": 1914.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2130.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2130.0, "10th_percentile": 2130.0, "90th_percentile": 2130.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2414.0, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2414.0, "10th_percentile": 2414.0, "90th_percentile": 2414.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1278.0, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1278.0, "10th_percentile": 1278.0, "90th_percentile": 1278.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2272.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2272.0, "10th_percentile": 2272.0, "90th_percentile": 2272.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2320.28, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2320.28, "10th_percentile": 2320.28, "90th_percentile": 2320.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Arthro/Surg Shld Debrd Exten", "code_information": [ { "code": "CASE-29823", "type": "LOCAL" }, { "code": "29823", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103856.51, "discounted_cash": 72699.56, "payers_information": [ { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6948.66, "10th_percentile": 6948.66, "90th_percentile": 6948.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6948.66, "10th_percentile": 6948.66, "90th_percentile": 6948.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6948.66, "10th_percentile": 6948.66, "90th_percentile": 6948.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6948.66, "10th_percentile": 6948.66, "90th_percentile": 6948.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6948.66, "10th_percentile": 6948.66, "90th_percentile": 6948.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6948.66, "10th_percentile": 6948.66, "90th_percentile": 6948.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 57.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 59925.22, "10th_percentile": 59925.22, "90th_percentile": 59925.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 57.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 59925.22, "10th_percentile": 59925.22, "90th_percentile": 59925.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 57.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 59405.94, "10th_percentile": 59405.94, "90th_percentile": 59405.94, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 67662.54, "10th_percentile": 67662.54, "90th_percentile": 67662.54, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": 58055.82, "10th_percentile": 58055.82, "90th_percentile": 58055.82, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 76.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 79657.97, "10th_percentile": 79657.97, "90th_percentile": 79657.97, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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": 103856.52, "10th_percentile": 103856.52, "90th_percentile": 103856.52, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH 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": 103856.52, "10th_percentile": 103856.52, "90th_percentile": 103856.52, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH 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": 103856.52, "10th_percentile": 103856.52, "90th_percentile": 103856.52, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 67893.4, "10th_percentile": 67893.4, "90th_percentile": 67893.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 71942.07, "10th_percentile": 71942.07, "90th_percentile": 71942.07, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_percentage": 34.8, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 36126.74, "10th_percentile": 36126.74, "90th_percentile": 36126.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_percentage": 25.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 26368.39, "10th_percentile": 26368.39, "90th_percentile": 26368.39, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19732.77, "10th_percentile": 19732.77, "90th_percentile": 19732.77, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 67662.54, "10th_percentile": 67662.54, "90th_percentile": 67662.54, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 76.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 79657.97, "10th_percentile": 79657.97, "90th_percentile": 79657.97, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19732.77, "10th_percentile": 19732.77, "90th_percentile": 19732.77, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 69999.3, "10th_percentile": 69999.3, "90th_percentile": 69999.3, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 39547.52, "10th_percentile": 39547.52, "90th_percentile": 39547.52, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 42153.48, "10th_percentile": 42153.48, "90th_percentile": 42153.48, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19732.77, "10th_percentile": 19732.77, "90th_percentile": 19732.77, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 88278.07, "10th_percentile": 88278.07, "90th_percentile": 88278.07, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_percentage": 45.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 46735.45, "10th_percentile": 46735.45, "90th_percentile": 46735.45, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 77892.43, "10th_percentile": 77892.43, "90th_percentile": 77892.43, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_percentage": 87.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 90874.45, "10th_percentile": 90874.45, "90th_percentile": 90874.45, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 84197.86, "10th_percentile": 84197.86, "90th_percentile": 84197.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 56446.05, "10th_percentile": 56446.05, "90th_percentile": 56446.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 49102.17, "10th_percentile": 49102.17, "90th_percentile": 49102.17, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 65365.71, "10th_percentile": 65365.71, "90th_percentile": 65365.71, "count": "1 through 10", "methodology": "percent of total billed charges" } ] } ] }, { "description": "HB Aspiration of Tarlov Cyst With Fibrin Glue Treatment - Unlisted", "code_information": [ { "code": "PX-76100135", "type": "CDM" }, { "code": "64999", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 138.28, "maximum": 2004.0, "setting": "outpatient", "gross_charge": 2004.0, "discounted_cash": 1402.8, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1262.52, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1262.52, "10th_percentile": 1262.52, "90th_percentile": 1262.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1637.27, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1637.27, "10th_percentile": 1637.27, "90th_percentile": 1637.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1210.42, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1210.42, "10th_percentile": 1210.42, "90th_percentile": 1210.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1210.42, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1210.42, "10th_percentile": 1210.42, "90th_percentile": 1210.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1120.24, "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": 1120.24, "10th_percentile": 1120.24, "90th_percentile": 1120.24, "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1637.27, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1637.27, "10th_percentile": 1637.27, "90th_percentile": 1637.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 907.81, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 907.81, "10th_percentile": 907.81, "90th_percentile": 907.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 967.93, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 967.93, "10th_percentile": 967.93, "90th_percentile": 967.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 1703.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1703.4, "10th_percentile": 1703.4, "90th_percentile": 1703.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1503.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1503.0, "10th_percentile": 1503.0, "90th_percentile": 1503.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1089.17, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1089.17, "10th_percentile": 1089.17, "90th_percentile": 1089.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1350.7, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1350.7, "10th_percentile": 1350.7, "90th_percentile": 1350.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1753.5, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1753.5, "10th_percentile": 1753.5, "90th_percentile": 1753.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1603.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1603.2, "10th_percentile": 1603.2, "90th_percentile": 1603.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 901.8, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 901.8, "10th_percentile": 901.8, "90th_percentile": 901.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 138.28, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 138.28, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 138.28, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 138.28, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 138.28, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 138.28, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 138.28, "10th_percentile": 138.28, "90th_percentile": 138.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 509.02, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 509.02, "10th_percentile": 509.02, "90th_percentile": 509.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 697.39, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 697.39, "10th_percentile": 697.39, "90th_percentile": 697.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1388.77, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1388.77, "10th_percentile": 1388.77, "90th_percentile": 1388.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1310.62, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1310.62, "10th_percentile": 1310.62, "90th_percentile": 1310.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 380.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 380.76, "10th_percentile": 380.76, "90th_percentile": 380.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 380.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 380.76, "10th_percentile": 380.76, "90th_percentile": 380.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 380.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 380.76, "10th_percentile": 380.76, "90th_percentile": 380.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2004.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2004.0, "10th_percentile": 2004.0, "90th_percentile": 2004.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2004.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2004.0, "10th_percentile": 2004.0, "90th_percentile": 2004.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 1305.61, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1305.61, "10th_percentile": 1305.61, "90th_percentile": 1305.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1305.61, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1305.61, "10th_percentile": 1305.61, "90th_percentile": 1305.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Assessment of Aphasia", "code_information": [ { "code": "PX-44000049", "type": "CDM" }, { "code": "96105", "type": "CPT" }, { "code": "0440", "type": "RC" } ], "standard_charges": [ { "minimum": 87.59, "maximum": 461.0, "setting": "outpatient", "gross_charge": 461.0, "discounted_cash": 322.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 278.44, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 278.44, "10th_percentile": 278.44, "90th_percentile": 278.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 278.44, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 278.44, "10th_percentile": 278.44, "90th_percentile": 278.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 300.34, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 300.34, "10th_percentile": 300.34, "90th_percentile": 300.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 257.7, "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": 257.7, "10th_percentile": 257.7, "90th_percentile": 257.7, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 290.43, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 290.43, "10th_percentile": 290.43, "90th_percentile": 290.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 376.64, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 376.64, "10th_percentile": 376.64, "90th_percentile": 376.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 87.59, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 87.59, "10th_percentile": 87.59, "90th_percentile": 87.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 87.59, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 87.59, "10th_percentile": 87.59, "90th_percentile": 87.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 87.59, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 87.59, "10th_percentile": 87.59, "90th_percentile": 87.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 461.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 461.0, "10th_percentile": 461.0, "90th_percentile": 461.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 461.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 461.0, "10th_percentile": 461.0, "90th_percentile": 461.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 301.49, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 301.49, "10th_percentile": 301.49, "90th_percentile": 301.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 117.09, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 117.09, "10th_percentile": 117.09, "90th_percentile": 117.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 319.47, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 319.47, "10th_percentile": 319.47, "90th_percentile": 319.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 160.43, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 160.43, "10th_percentile": 160.43, "90th_percentile": 160.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 461.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 461.0, "10th_percentile": 461.0, "90th_percentile": 461.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 403.38, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 403.38, "10th_percentile": 403.38, "90th_percentile": 403.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 300.34, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 300.34, "10th_percentile": 300.34, "90th_percentile": 300.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 250.55, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 250.55, "10th_percentile": 250.55, "90th_percentile": 250.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 310.71, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 310.71, "10th_percentile": 310.71, "90th_percentile": 310.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 345.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 345.75, "10th_percentile": 345.75, "90th_percentile": 345.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 391.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 391.85, "10th_percentile": 391.85, "90th_percentile": 391.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 207.45, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 207.45, "10th_percentile": 207.45, "90th_percentile": 207.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 368.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 368.8, "10th_percentile": 368.8, "90th_percentile": 368.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 376.64, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 376.64, "10th_percentile": 376.64, "90th_percentile": 376.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 231.42, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 231.42, "10th_percentile": 231.42, "90th_percentile": 231.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 308.41, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 308.41, "10th_percentile": 308.41, "90th_percentile": 308.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 222.66, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 222.66, "10th_percentile": 222.66, "90th_percentile": 222.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 208.83, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 208.83, "10th_percentile": 208.83, "90th_percentile": 208.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Autonomic Nrv Adrenrg Inervj", "code_information": [ { "code": "PX-92200019", "type": "CDM" }, { "code": "95922", "type": "CPT" }, { "code": "0922", "type": "RC" } ], "standard_charges": [ { "minimum": 258.59, "maximum": 1361.0, "setting": "outpatient", "gross_charge": 1361.0, "discounted_cash": 952.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 822.04, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 822.04, "10th_percentile": 822.04, "90th_percentile": 822.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 822.04, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 822.04, "10th_percentile": 822.04, "90th_percentile": 822.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 886.69, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 886.69, "10th_percentile": 886.69, "90th_percentile": 886.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 760.8, "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": 760.8, "10th_percentile": 760.8, "90th_percentile": 760.8, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 857.43, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 857.43, "10th_percentile": 857.43, "90th_percentile": 857.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1111.94, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1111.94, "10th_percentile": 1111.94, "90th_percentile": 1111.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 258.59, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 258.59, "10th_percentile": 258.59, "90th_percentile": 258.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 258.59, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 258.59, "10th_percentile": 258.59, "90th_percentile": 258.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 258.59, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 258.59, "10th_percentile": 258.59, "90th_percentile": 258.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1361.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1361.0, "10th_percentile": 1361.0, "90th_percentile": 1361.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1361.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1361.0, "10th_percentile": 1361.0, "90th_percentile": 1361.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 890.09, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 890.09, "10th_percentile": 890.09, "90th_percentile": 890.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 345.69, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 345.69, "10th_percentile": 345.69, "90th_percentile": 345.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 943.17, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 943.17, "10th_percentile": 943.17, "90th_percentile": 943.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 473.63, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 473.63, "10th_percentile": 473.63, "90th_percentile": 473.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1361.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1361.0, "10th_percentile": 1361.0, "90th_percentile": 1361.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1190.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1190.88, "10th_percentile": 1190.88, "90th_percentile": 1190.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 886.69, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 886.69, "10th_percentile": 886.69, "90th_percentile": 886.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 739.7, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 739.7, "10th_percentile": 739.7, "90th_percentile": 739.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 917.31, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 917.31, "10th_percentile": 917.31, "90th_percentile": 917.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1020.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1020.75, "10th_percentile": 1020.75, "90th_percentile": 1020.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1156.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1156.85, "10th_percentile": 1156.85, "90th_percentile": 1156.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 612.45, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 612.45, "10th_percentile": 612.45, "90th_percentile": 612.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1088.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1088.8, "10th_percentile": 1088.8, "90th_percentile": 1088.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1111.94, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1111.94, "10th_percentile": 1111.94, "90th_percentile": 1111.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 683.22, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 683.22, "10th_percentile": 683.22, "90th_percentile": 683.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 910.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 910.51, "10th_percentile": 910.51, "90th_percentile": 910.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 657.36, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 657.36, "10th_percentile": 657.36, "90th_percentile": 657.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 616.53, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 616.53, "10th_percentile": 616.53, "90th_percentile": 616.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Behavior Counsel Obesity 15m", "code_information": [ { "code": "PX-94000032", "type": "CDM" }, { "code": "G0447", "type": "CPT" }, { "code": "0940", "type": "RC" } ], "standard_charges": [ { "minimum": 10.35, "maximum": 150.0, "setting": "outpatient", "gross_charge": 150.0, "discounted_cash": 105.0, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 90.6, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.6, "10th_percentile": 90.6, "90th_percentile": 90.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 90.6, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.6, "10th_percentile": 90.6, "90th_percentile": 90.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 97.73, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 97.73, "10th_percentile": 97.73, "90th_percentile": 97.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 83.85, "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": 83.85, "10th_percentile": 83.85, "90th_percentile": 83.85, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 94.5, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.5, "10th_percentile": 94.5, "90th_percentile": 94.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 122.55, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.55, "10th_percentile": 122.55, "90th_percentile": 122.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 28.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.5, "10th_percentile": 28.5, "90th_percentile": 28.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 28.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.5, "10th_percentile": 28.5, "90th_percentile": 28.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 28.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.5, "10th_percentile": 28.5, "90th_percentile": 28.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 150.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 150.0, "10th_percentile": 150.0, "90th_percentile": 150.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 150.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 150.0, "10th_percentile": 150.0, "90th_percentile": 150.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 98.1, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.1, "10th_percentile": 98.1, "90th_percentile": 98.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 38.1, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 38.1, "10th_percentile": 38.1, "90th_percentile": 38.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 103.95, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 103.95, "10th_percentile": 103.95, "90th_percentile": 103.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 52.2, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 52.2, "10th_percentile": 52.2, "90th_percentile": 52.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 150.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 150.0, "10th_percentile": 150.0, "90th_percentile": 150.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 131.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 131.25, "10th_percentile": 131.25, "90th_percentile": 131.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 97.73, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 97.73, "10th_percentile": 97.73, "90th_percentile": 97.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 81.53, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 81.53, "10th_percentile": 81.53, "90th_percentile": 81.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 101.1, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 101.1, "10th_percentile": 101.1, "90th_percentile": 101.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 112.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 112.5, "10th_percentile": 112.5, "90th_percentile": 112.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 127.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 127.5, "10th_percentile": 127.5, "90th_percentile": 127.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 67.5, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 67.5, "10th_percentile": 67.5, "90th_percentile": 67.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 120.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 120.0, "10th_percentile": 120.0, "90th_percentile": 120.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.35, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 122.55, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.55, "10th_percentile": 122.55, "90th_percentile": 122.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 75.3, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 75.3, "10th_percentile": 75.3, "90th_percentile": 75.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 100.35, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.35, "10th_percentile": 100.35, "90th_percentile": 100.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 72.45, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.45, "10th_percentile": 72.45, "90th_percentile": 72.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 67.95, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.95, "10th_percentile": 67.95, "90th_percentile": 67.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Biopsy Abdominal Wall Mass - Unlisted", "code_information": [ { "code": "PX-76100808", "type": "CDM" }, { "code": "22999", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 2267.03, "maximum": 4516.0, "setting": "outpatient", "gross_charge": 4516.0, "discounted_cash": 3161.2, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4516.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4516.0, "10th_percentile": 4516.0, "90th_percentile": 4516.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2267.03, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2267.03, "10th_percentile": 2267.03, "90th_percentile": 2267.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3021.2, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3021.2, "10th_percentile": 3021.2, "90th_percentile": 3021.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Biopsy Penis Separate Procedure", "code_information": [ { "code": "PX-76100587", "type": "CDM" }, { "code": "54100", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 3573.24, "maximum": 7118.0, "setting": "outpatient", "gross_charge": 7118.0, "discounted_cash": 4982.6, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7118.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7118.0, "10th_percentile": 7118.0, "90th_percentile": 7118.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 3573.24, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3573.24, "10th_percentile": 3573.24, "90th_percentile": 3573.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 4761.94, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4761.94, "10th_percentile": 4761.94, "90th_percentile": 4761.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Biopsy/Removal Lymph Nodes Open Superficial", "code_information": [ { "code": "PX-36100529", "type": "CDM" }, { "code": "38500", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 4895.5, "maximum": 9752.0, "setting": "outpatient", "gross_charge": 9752.0, "discounted_cash": 6826.4, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9752.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 9752.0, "10th_percentile": 9752.0, "90th_percentile": 9752.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 4895.5, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4895.5, "10th_percentile": 4895.5, "90th_percentile": 4895.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 6524.09, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6524.09, "10th_percentile": 6524.09, "90th_percentile": 6524.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Biopsy/Removal Lymph Nodes Open Superficial", "code_information": [ { "code": "PX-36100529", "type": "CDM" }, { "code": "38500", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 1852.88, "maximum": 9752.0, "setting": "outpatient", "gross_charge": 9752.0, "discounted_cash": 6826.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5451.37, "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": 5451.37, "10th_percentile": 5451.37, "90th_percentile": 5451.37, "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": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 4417.66, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4417.66, "10th_percentile": 4417.66, "90th_percentile": 4417.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 4710.22, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4710.22, "10th_percentile": 4710.22, "90th_percentile": 4710.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 8289.2, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 8289.2, "10th_percentile": 8289.2, "90th_percentile": 8289.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 7314.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 7314.0, "10th_percentile": 7314.0, "90th_percentile": 7314.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 5300.21, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 5300.21, "10th_percentile": 5300.21, "90th_percentile": 5300.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 6572.85, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 6572.85, "10th_percentile": 6572.85, "90th_percentile": 6572.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 8533.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 8533.0, "10th_percentile": 8533.0, "90th_percentile": 8533.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 7801.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 7801.6, "10th_percentile": 7801.6, "90th_percentile": 7801.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 4388.4, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 4388.4, "10th_percentile": 4388.4, "90th_percentile": 4388.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1852.88, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1852.88, "10th_percentile": 1852.88, "90th_percentile": 1852.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1852.88, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1852.88, "10th_percentile": 1852.88, "90th_percentile": 1852.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 2477.01, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 2477.01, "10th_percentile": 2477.01, "90th_percentile": 2477.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 3393.7, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 3393.7, "10th_percentile": 3393.7, "90th_percentile": 3393.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 6758.14, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6758.14, "10th_percentile": 6758.14, "90th_percentile": 6758.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 6377.81, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6377.81, "10th_percentile": 6377.81, "90th_percentile": 6377.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1852.88, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1852.88, "10th_percentile": 1852.88, "90th_percentile": 1852.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9752.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9752.0, "10th_percentile": 9752.0, "90th_percentile": 9752.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9752.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9752.0, "10th_percentile": 9752.0, "90th_percentile": 9752.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 6353.43, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 6353.43, "10th_percentile": 6353.43, "90th_percentile": 6353.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 6353.43, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 6353.43, "10th_percentile": 6353.43, "90th_percentile": 6353.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Brachytx Isodose Intermed", "code_information": [ { "code": "PX-33300017", "type": "CDM" }, { "code": "77317", "type": "CPT" }, { "code": "0333", "type": "RC" } ], "standard_charges": [ { "minimum": 401.3, "maximum": 5816.0, "setting": "outpatient", "gross_charge": 5816.0, "discounted_cash": 4071.2, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3512.86, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3512.86, "10th_percentile": 3512.86, "90th_percentile": 3512.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3512.86, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3512.86, "10th_percentile": 3512.86, "90th_percentile": 3512.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3789.12, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3789.12, "10th_percentile": 3789.12, "90th_percentile": 3789.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3251.14, "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": 3251.14, "10th_percentile": 3251.14, "90th_percentile": 3251.14, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3664.08, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3664.08, "10th_percentile": 3664.08, "90th_percentile": 3664.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4751.67, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4751.67, "10th_percentile": 4751.67, "90th_percentile": 4751.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1105.04, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1105.04, "10th_percentile": 1105.04, "90th_percentile": 1105.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1105.04, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1105.04, "10th_percentile": 1105.04, "90th_percentile": 1105.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1105.04, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1105.04, "10th_percentile": 1105.04, "90th_percentile": 1105.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5816.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5816.0, "10th_percentile": 5816.0, "90th_percentile": 5816.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5816.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5816.0, "10th_percentile": 5816.0, "90th_percentile": 5816.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3803.66, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3803.66, "10th_percentile": 3803.66, "90th_percentile": 3803.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1477.26, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1477.26, "10th_percentile": 1477.26, "90th_percentile": 1477.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 4030.49, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4030.49, "10th_percentile": 4030.49, "90th_percentile": 4030.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2023.97, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2023.97, "10th_percentile": 2023.97, "90th_percentile": 2023.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5816.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5816.0, "10th_percentile": 5816.0, "90th_percentile": 5816.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 5089.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 5089.0, "10th_percentile": 5089.0, "90th_percentile": 5089.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3789.12, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3789.12, "10th_percentile": 3789.12, "90th_percentile": 3789.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3161.0, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3161.0, "10th_percentile": 3161.0, "90th_percentile": 3161.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3919.98, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3919.98, "10th_percentile": 3919.98, "90th_percentile": 3919.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4362.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4362.0, "10th_percentile": 4362.0, "90th_percentile": 4362.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 4943.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4943.6, "10th_percentile": 4943.6, "90th_percentile": 4943.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2617.2, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2617.2, "10th_percentile": 2617.2, "90th_percentile": 2617.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4652.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 4652.8, "10th_percentile": 4652.8, "90th_percentile": 4652.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 401.3, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 401.3, "10th_percentile": 401.3, "90th_percentile": 401.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 401.3, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 401.3, "10th_percentile": 401.3, "90th_percentile": 401.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 401.3, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 401.3, "10th_percentile": 401.3, "90th_percentile": 401.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 401.3, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 401.3, "10th_percentile": 401.3, "90th_percentile": 401.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 401.3, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 401.3, "10th_percentile": 401.3, "90th_percentile": 401.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 401.3, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 401.3, "10th_percentile": 401.3, "90th_percentile": 401.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4751.67, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4751.67, "10th_percentile": 4751.67, "90th_percentile": 4751.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2919.63, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2919.63, "10th_percentile": 2919.63, "90th_percentile": 2919.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3890.9, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3890.9, "10th_percentile": 3890.9, "90th_percentile": 3890.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Btw-Work Hard Ea Addl Hour", "code_information": [ { "code": "PX-42000044", "type": "CDM" }, { "code": "97546", "type": "CPT" }, { "code": "0420", "type": "RC" } ], "standard_charges": [ { "minimum": 10.83, "maximum": 157.0, "setting": "outpatient", "gross_charge": 157.0, "discounted_cash": 109.9, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 94.83, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.83, "10th_percentile": 94.83, "90th_percentile": 94.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 94.83, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.83, "10th_percentile": 94.83, "90th_percentile": 94.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 102.29, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 102.29, "10th_percentile": 102.29, "90th_percentile": 102.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 87.76, "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": 87.76, "10th_percentile": 87.76, "90th_percentile": 87.76, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 98.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.91, "10th_percentile": 98.91, "90th_percentile": 98.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 128.27, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 128.27, "10th_percentile": 128.27, "90th_percentile": 128.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 29.83, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 29.83, "10th_percentile": 29.83, "90th_percentile": 29.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 29.83, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 29.83, "10th_percentile": 29.83, "90th_percentile": 29.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 29.83, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 29.83, "10th_percentile": 29.83, "90th_percentile": 29.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 157.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 157.0, "10th_percentile": 157.0, "90th_percentile": 157.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 157.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 157.0, "10th_percentile": 157.0, "90th_percentile": 157.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 102.68, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.68, "10th_percentile": 102.68, "90th_percentile": 102.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 39.88, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 39.88, "10th_percentile": 39.88, "90th_percentile": 39.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 108.8, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 108.8, "10th_percentile": 108.8, "90th_percentile": 108.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 54.64, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 54.64, "10th_percentile": 54.64, "90th_percentile": 54.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 157.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 157.0, "10th_percentile": 157.0, "90th_percentile": 157.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 137.38, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 137.38, "10th_percentile": 137.38, "90th_percentile": 137.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 102.29, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 102.29, "10th_percentile": 102.29, "90th_percentile": 102.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 85.33, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 85.33, "10th_percentile": 85.33, "90th_percentile": 85.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 105.82, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 105.82, "10th_percentile": 105.82, "90th_percentile": 105.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 117.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 117.75, "10th_percentile": 117.75, "90th_percentile": 117.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 133.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 133.45, "10th_percentile": 133.45, "90th_percentile": 133.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 70.65, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 70.65, "10th_percentile": 70.65, "90th_percentile": 70.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 125.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 125.6, "10th_percentile": 125.6, "90th_percentile": 125.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.83, "10th_percentile": 10.83, "90th_percentile": 10.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.83, "10th_percentile": 10.83, "90th_percentile": 10.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.83, "10th_percentile": 10.83, "90th_percentile": 10.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.83, "10th_percentile": 10.83, "90th_percentile": 10.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.83, "10th_percentile": 10.83, "90th_percentile": 10.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 10.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.83, "10th_percentile": 10.83, "90th_percentile": 10.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 128.27, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 128.27, "10th_percentile": 128.27, "90th_percentile": 128.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 78.81, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.81, "10th_percentile": 78.81, "90th_percentile": 78.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 105.03, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 105.03, "10th_percentile": 105.03, "90th_percentile": 105.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 75.83, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 75.83, "10th_percentile": 75.83, "90th_percentile": 75.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 71.12, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.12, "10th_percentile": 71.12, "90th_percentile": 71.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB C-Peptide", "code_information": [ { "code": "PX-30105203", "type": "CDM" }, { "code": "84681", "type": "CPT" }, { "code": "0301", "type": "RC" } ], "standard_charges": [ { "minimum": 40.09, "maximum": 211.0, "setting": "outpatient", "gross_charge": 211.0, "discounted_cash": 147.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 127.44, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 127.44, "10th_percentile": 127.44, "90th_percentile": 127.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 127.44, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 127.44, "10th_percentile": 127.44, "90th_percentile": 127.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 137.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 137.47, "10th_percentile": 137.47, "90th_percentile": 137.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 117.95, "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": 117.95, "10th_percentile": 117.95, "90th_percentile": 117.95, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 132.93, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 132.93, "10th_percentile": 132.93, "90th_percentile": 132.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 172.39, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 172.39, "10th_percentile": 172.39, "90th_percentile": 172.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 179.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 179.35, "10th_percentile": 179.35, "90th_percentile": 179.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 211.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 211.0, "10th_percentile": 211.0, "90th_percentile": 211.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 168.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 168.8, "10th_percentile": 168.8, "90th_percentile": 168.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 94.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 94.95, "10th_percentile": 94.95, "90th_percentile": 94.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 142.21, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 142.21, "10th_percentile": 142.21, "90th_percentile": 142.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 158.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 158.25, "10th_percentile": 158.25, "90th_percentile": 158.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 184.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 184.63, "10th_percentile": 184.63, "90th_percentile": 184.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 114.68, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 114.68, "10th_percentile": 114.68, "90th_percentile": 114.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 137.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 137.47, "10th_percentile": 137.47, "90th_percentile": 137.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 172.39, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 172.39, "10th_percentile": 172.39, "90th_percentile": 172.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 53.59, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 53.59, "10th_percentile": 53.59, "90th_percentile": 53.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 73.43, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% 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 Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 146.22, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.22, "10th_percentile": 146.22, "90th_percentile": 146.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 211.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 211.0, "10th_percentile": 211.0, "90th_percentile": 211.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 211.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 211.0, "10th_percentile": 211.0, "90th_percentile": 211.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 40.09, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 40.09, "10th_percentile": 40.09, "90th_percentile": 40.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 40.09, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 40.09, "10th_percentile": 40.09, "90th_percentile": 40.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 40.09, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 40.09, "10th_percentile": 40.09, "90th_percentile": 40.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB CT Angio Abdominal Arteries", "code_information": [ { "code": "PX-35200038", "type": "CDM" }, { "code": "75635", "type": "CPT" }, { "code": "0352", "type": "RC" } ], "standard_charges": [ { "minimum": 1055.83, "maximum": 5557.0, "setting": "outpatient", "gross_charge": 5557.0, "discounted_cash": 3889.9, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3356.43, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3356.43, "10th_percentile": 3356.43, "90th_percentile": 3356.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3356.43, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3356.43, "10th_percentile": 3356.43, "90th_percentile": 3356.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3620.39, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3620.39, "10th_percentile": 3620.39, "90th_percentile": 3620.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3106.36, "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": 3106.36, "10th_percentile": 3106.36, "90th_percentile": 3106.36, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3500.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3500.91, "10th_percentile": 3500.91, "90th_percentile": 3500.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4540.07, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4540.07, "10th_percentile": 4540.07, "90th_percentile": 4540.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1055.83, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1055.83, "10th_percentile": 1055.83, "90th_percentile": 1055.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1055.83, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1055.83, "10th_percentile": 1055.83, "90th_percentile": 1055.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1055.83, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1055.83, "10th_percentile": 1055.83, "90th_percentile": 1055.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5557.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5557.0, "10th_percentile": 5557.0, "90th_percentile": 5557.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5557.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5557.0, "10th_percentile": 5557.0, "90th_percentile": 5557.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1411.48, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1411.48, "10th_percentile": 1411.48, "90th_percentile": 1411.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3851.0, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3851.0, "10th_percentile": 3851.0, "90th_percentile": 3851.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1933.84, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1933.84, "10th_percentile": 1933.84, "90th_percentile": 1933.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5557.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5557.0, "10th_percentile": 5557.0, "90th_percentile": 5557.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4862.38, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4862.38, "10th_percentile": 4862.38, "90th_percentile": 4862.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3620.39, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3620.39, "10th_percentile": 3620.39, "90th_percentile": 3620.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3020.23, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3020.23, "10th_percentile": 3020.23, "90th_percentile": 3020.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3745.42, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3745.42, "10th_percentile": 3745.42, "90th_percentile": 3745.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4167.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4167.75, "10th_percentile": 4167.75, "90th_percentile": 4167.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 4723.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4723.45, "10th_percentile": 4723.45, "90th_percentile": 4723.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2500.65, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2500.65, "10th_percentile": 2500.65, "90th_percentile": 2500.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4445.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 4445.6, "10th_percentile": 4445.6, "90th_percentile": 4445.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4540.07, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4540.07, "10th_percentile": 4540.07, "90th_percentile": 4540.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB CT Angio Upr Extrm W/O&W/Dye", "code_information": [ { "code": "PX-35200024", "type": "CDM" }, { "code": "73206", "type": "CPT" }, { "code": "0352", "type": "RC" } ], "standard_charges": [ { "minimum": 821.37, "maximum": 4323.0, "setting": "outpatient", "gross_charge": 4323.0, "discounted_cash": 3026.1, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2611.09, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2611.09, "10th_percentile": 2611.09, "90th_percentile": 2611.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2611.09, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2611.09, "10th_percentile": 2611.09, "90th_percentile": 2611.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2816.43, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2816.43, "10th_percentile": 2816.43, "90th_percentile": 2816.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2416.56, "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": 2416.56, "10th_percentile": 2416.56, "90th_percentile": 2416.56, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2723.49, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2723.49, "10th_percentile": 2723.49, "90th_percentile": 2723.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3531.89, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3531.89, "10th_percentile": 3531.89, "90th_percentile": 3531.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 821.37, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 821.37, "10th_percentile": 821.37, "90th_percentile": 821.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 821.37, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 821.37, "10th_percentile": 821.37, "90th_percentile": 821.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 821.37, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 821.37, "10th_percentile": 821.37, "90th_percentile": 821.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4323.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4323.0, "10th_percentile": 4323.0, "90th_percentile": 4323.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4323.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4323.0, "10th_percentile": 4323.0, "90th_percentile": 4323.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1098.04, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1098.04, "10th_percentile": 1098.04, "90th_percentile": 1098.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2995.84, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2995.84, "10th_percentile": 2995.84, "90th_percentile": 2995.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1504.4, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1504.4, "10th_percentile": 1504.4, "90th_percentile": 1504.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4323.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4323.0, "10th_percentile": 4323.0, "90th_percentile": 4323.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 3782.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 3782.63, "10th_percentile": 3782.63, "90th_percentile": 3782.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2816.43, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2816.43, "10th_percentile": 2816.43, "90th_percentile": 2816.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2349.55, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2349.55, "10th_percentile": 2349.55, "90th_percentile": 2349.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2913.7, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2913.7, "10th_percentile": 2913.7, "90th_percentile": 2913.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3242.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 3242.25, "10th_percentile": 3242.25, "90th_percentile": 3242.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 3674.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 3674.55, "10th_percentile": 3674.55, "90th_percentile": 3674.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1945.35, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1945.35, "10th_percentile": 1945.35, "90th_percentile": 1945.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 3458.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 3458.4, "10th_percentile": 3458.4, "90th_percentile": 3458.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 3531.89, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3531.89, "10th_percentile": 3531.89, "90th_percentile": 3531.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Canalith Repositioning Proc", "code_information": [ { "code": "PX-47000010", "type": "CDM" }, { "code": "95992", "type": "CPT" }, { "code": "0470", "type": "RC" } ], "standard_charges": [ { "minimum": 18.98, "maximum": 275.0, "setting": "outpatient", "gross_charge": 275.0, "discounted_cash": 192.5, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 166.1, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 166.1, "10th_percentile": 166.1, "90th_percentile": 166.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 166.1, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 166.1, "10th_percentile": 166.1, "90th_percentile": 166.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 179.16, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 179.16, "10th_percentile": 179.16, "90th_percentile": 179.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 153.73, "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": 153.73, "10th_percentile": 153.73, "90th_percentile": 153.73, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 173.25, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 173.25, "10th_percentile": 173.25, "90th_percentile": 173.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 224.68, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 224.68, "10th_percentile": 224.68, "90th_percentile": 224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 52.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 52.25, "10th_percentile": 52.25, "90th_percentile": 52.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 52.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 52.25, "10th_percentile": 52.25, "90th_percentile": 52.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 52.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 52.25, "10th_percentile": 52.25, "90th_percentile": 52.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.0, "10th_percentile": 275.0, "90th_percentile": 275.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.0, "10th_percentile": 275.0, "90th_percentile": 275.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 179.85, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.85, "10th_percentile": 179.85, "90th_percentile": 179.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 69.85, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 69.85, "10th_percentile": 69.85, "90th_percentile": 69.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 190.58, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 190.58, "10th_percentile": 190.58, "90th_percentile": 190.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 95.7, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 95.7, "10th_percentile": 95.7, "90th_percentile": 95.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 275.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 275.0, "10th_percentile": 275.0, "90th_percentile": 275.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 240.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% 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; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 179.16, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 179.16, "10th_percentile": 179.16, "90th_percentile": 179.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 149.46, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 149.46, "10th_percentile": 149.46, "90th_percentile": 149.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 185.35, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 185.35, "10th_percentile": 185.35, "90th_percentile": 185.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 206.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 206.25, "10th_percentile": 206.25, "90th_percentile": 206.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 233.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 233.75, "10th_percentile": 233.75, "90th_percentile": 233.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 123.75, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 123.75, "10th_percentile": 123.75, "90th_percentile": 123.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 220.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 220.0, "10th_percentile": 220.0, "90th_percentile": 220.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 18.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 18.98, "10th_percentile": 18.98, "90th_percentile": 18.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 18.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 18.98, "10th_percentile": 18.98, "90th_percentile": 18.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 18.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 18.98, "10th_percentile": 18.98, "90th_percentile": 18.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 18.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 18.98, "10th_percentile": 18.98, "90th_percentile": 18.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 18.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 18.98, "10th_percentile": 18.98, "90th_percentile": 18.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 18.98, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 18.98, "10th_percentile": 18.98, "90th_percentile": 18.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 224.68, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 224.68, "10th_percentile": 224.68, "90th_percentile": 224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 138.05, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.05, "10th_percentile": 138.05, "90th_percentile": 138.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 183.98, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 183.98, "10th_percentile": 183.98, "90th_percentile": 183.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 132.83, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 132.83, "10th_percentile": 132.83, "90th_percentile": 132.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 124.58, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.58, "10th_percentile": 124.58, "90th_percentile": 124.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Capillary Blood Gas Epoc", "code_information": [ { "code": "PX-30001250", "type": "CDM" }, { "code": "82803", "type": "CPT" }, { "code": "0301", "type": "RC" } ], "standard_charges": [ { "minimum": 81.32, "maximum": 428.0, "setting": "outpatient", "gross_charge": 428.0, "discounted_cash": 299.6, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 258.51, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.51, "10th_percentile": 258.51, "90th_percentile": 258.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 258.51, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.51, "10th_percentile": 258.51, "90th_percentile": 258.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 278.84, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 278.84, "10th_percentile": 278.84, "90th_percentile": 278.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 239.25, "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": 239.25, "10th_percentile": 239.25, "90th_percentile": 239.25, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 269.64, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 269.64, "10th_percentile": 269.64, "90th_percentile": 269.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 349.68, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 349.68, "10th_percentile": 349.68, "90th_percentile": 349.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 363.8, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 363.8, "10th_percentile": 363.8, "90th_percentile": 363.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 428.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 428.0, "10th_percentile": 428.0, "90th_percentile": 428.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 342.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 342.4, "10th_percentile": 342.4, "90th_percentile": 342.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 192.6, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 192.6, "10th_percentile": 192.6, "90th_percentile": 192.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 288.47, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 288.47, "10th_percentile": 288.47, "90th_percentile": 288.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 321.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 321.0, "10th_percentile": 321.0, "90th_percentile": 321.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 374.5, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 374.5, "10th_percentile": 374.5, "90th_percentile": 374.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 232.62, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 232.62, "10th_percentile": 232.62, "90th_percentile": 232.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 278.84, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 278.84, "10th_percentile": 278.84, "90th_percentile": 278.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 349.68, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 349.68, "10th_percentile": 349.68, "90th_percentile": 349.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 108.71, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 108.71, "10th_percentile": 108.71, "90th_percentile": 108.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 148.94, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 90.13, "10th_percentile": 90.13, "90th_percentile": 90.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 296.6, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 296.6, "10th_percentile": 296.6, "90th_percentile": 296.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 428.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 428.0, "10th_percentile": 428.0, "90th_percentile": 428.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 428.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 428.0, "10th_percentile": 428.0, "90th_percentile": 428.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 81.32, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 81.32, "10th_percentile": 81.32, "90th_percentile": 81.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 81.32, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 81.32, "10th_percentile": 81.32, "90th_percentile": 81.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 81.32, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 81.32, "10th_percentile": 81.32, "90th_percentile": 81.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Case Management; Each 15 Minutes; Transition/Linkage", "code_information": [ { "code": "PX-99000004", "type": "CDM" }, { "code": "T1016", "type": "HCPCS" }, { "code": "0990", "type": "RC" } ], "standard_charges": [ { "minimum": 5.18, "maximum": 75.0, "setting": "outpatient", "gross_charge": 75.0, "discounted_cash": 52.5, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 65.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 65.63, "10th_percentile": 65.63, "90th_percentile": 65.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 33.75, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 33.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 63.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 63.75, "10th_percentile": 63.75, "90th_percentile": 63.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 40.76, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 40.76, "10th_percentile": 40.76, "90th_percentile": 40.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 56.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 56.25, "10th_percentile": 56.25, "90th_percentile": 56.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 50.55, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 50.55, "10th_percentile": 50.55, "90th_percentile": 50.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 48.86, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 48.86, "10th_percentile": 48.86, "90th_percentile": 48.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 75.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 75.0, "10th_percentile": 75.0, "90th_percentile": 75.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 60.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 60.0, "10th_percentile": 60.0, "90th_percentile": 60.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 14.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 14.25, "10th_percentile": 14.25, "90th_percentile": 14.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 14.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 14.25, "10th_percentile": 14.25, "90th_percentile": 14.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 61.13, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.13, "10th_percentile": 61.13, "90th_percentile": 61.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 50.18, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.18, "10th_percentile": 50.18, "90th_percentile": 50.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 37.65, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.65, "10th_percentile": 37.65, "90th_percentile": 37.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 33.98, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.98, "10th_percentile": 33.98, "90th_percentile": 33.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 36.23, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.23, "10th_percentile": 36.23, "90th_percentile": 36.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 49.05, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 51.98, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.98, "10th_percentile": 51.98, "90th_percentile": 51.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 19.05, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 19.05, "10th_percentile": 19.05, "90th_percentile": 19.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 26.1, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% 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 Outpatient Services; 34.8% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.0, "10th_percentile": 75.0, "90th_percentile": 75.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.0, "10th_percentile": 75.0, "90th_percentile": 75.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 14.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 14.25, "10th_percentile": 14.25, "90th_percentile": 14.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 50.3, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.3, "10th_percentile": 50.3, "90th_percentile": 50.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 47.33, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.33, "10th_percentile": 47.33, "90th_percentile": 47.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 42.26, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.26, "10th_percentile": 42.26, "90th_percentile": 42.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 61.13, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.13, "10th_percentile": 61.13, "90th_percentile": 61.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 41.93, "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": 41.93, "10th_percentile": 41.93, "90th_percentile": 41.93, "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": "VWH BCBS HMO", "standard_charge_dollar": 48.86, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 48.86, "10th_percentile": 48.86, "90th_percentile": 48.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 5.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 5.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 5.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 5.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 5.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 5.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Cell Count, Body Fluid or CSF W/Differential", "code_information": [ { "code": "PX-30511390", "type": "CDM" }, { "code": "89051", "type": "CPT" }, { "code": "0300", "type": "RC" } ], "standard_charges": [ { "minimum": 21.28, "maximum": 112.0, "setting": "outpatient", "gross_charge": 112.0, "discounted_cash": 78.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 67.65, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.65, "10th_percentile": 67.65, "90th_percentile": 67.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 67.65, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.65, "10th_percentile": 67.65, "90th_percentile": 67.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 72.97, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 72.97, "10th_percentile": 72.97, "90th_percentile": 72.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 62.61, "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": 62.61, "10th_percentile": 62.61, "90th_percentile": 62.61, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 70.56, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.56, "10th_percentile": 70.56, "90th_percentile": 70.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 91.5, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.5, "10th_percentile": 91.5, "90th_percentile": 91.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 21.28, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 5.6, "10th_percentile": 5.6, "90th_percentile": 5.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 21.28, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 21.28, "10th_percentile": 21.28, "90th_percentile": 21.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 21.28, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 21.28, "10th_percentile": 21.28, "90th_percentile": 21.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 112.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 112.0, "10th_percentile": 112.0, "90th_percentile": 112.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 112.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 112.0, "10th_percentile": 112.0, "90th_percentile": 112.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 28.45, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 28.45, "10th_percentile": 28.45, "90th_percentile": 28.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 77.62, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.62, "10th_percentile": 77.62, "90th_percentile": 77.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 38.98, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 38.98, "10th_percentile": 38.98, "90th_percentile": 38.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 112.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 112.0, "10th_percentile": 112.0, "90th_percentile": 112.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 98.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 98.0, "10th_percentile": 98.0, "90th_percentile": 98.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 72.97, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 72.97, "10th_percentile": 72.97, "90th_percentile": 72.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 60.87, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 60.87, "10th_percentile": 60.87, "90th_percentile": 60.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 75.49, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 75.49, "10th_percentile": 75.49, "90th_percentile": 75.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 84.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 84.0, "10th_percentile": 84.0, "90th_percentile": 84.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 95.2, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 95.2, "10th_percentile": 95.2, "90th_percentile": 95.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 50.4, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 89.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 89.6, "10th_percentile": 89.6, "90th_percentile": 89.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 91.5, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.5, "10th_percentile": 91.5, "90th_percentile": 91.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Central Line Dressing", "code_information": [ { "code": "PX-27205018", "type": "CDM" }, { "code": "27205018", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 49.97, "maximum": 263.0, "setting": "outpatient", "gross_charge": 263.0, "discounted_cash": 184.1, "payers_information": [ { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 263.0, "10th_percentile": 263.0, "90th_percentile": 263.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 263.0, "10th_percentile": 263.0, "90th_percentile": 263.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 263.0, "10th_percentile": 263.0, "90th_percentile": 263.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 263.0, "10th_percentile": 263.0, "90th_percentile": 263.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 263.0, "10th_percentile": 263.0, "90th_percentile": 263.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 263.0, "10th_percentile": 263.0, "90th_percentile": 263.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 142.94, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 142.94, "10th_percentile": 142.94, "90th_percentile": 142.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 210.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 210.4, "10th_percentile": 210.4, "90th_percentile": 210.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 230.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 230.13, "10th_percentile": 230.13, "90th_percentile": 230.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 197.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 197.25, "10th_percentile": 197.25, "90th_percentile": 197.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 118.35, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 118.35, "10th_percentile": 118.35, "90th_percentile": 118.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 223.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 223.55, "10th_percentile": 223.55, "90th_percentile": 223.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 127.03, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 127.03, "10th_percentile": 127.03, "90th_percentile": 127.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 119.14, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 119.14, "10th_percentile": 119.14, "90th_percentile": 119.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 177.26, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 177.26, "10th_percentile": 177.26, "90th_percentile": 177.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 214.35, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 214.35, "10th_percentile": 214.35, "90th_percentile": 214.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 171.34, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 171.34, "10th_percentile": 171.34, "90th_percentile": 171.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 49.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 49.97, "10th_percentile": 49.97, "90th_percentile": 49.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 263.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 263.0, "10th_percentile": 263.0, "90th_percentile": 263.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 175.95, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 175.95, "10th_percentile": 175.95, "90th_percentile": 175.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 132.03, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 132.03, "10th_percentile": 132.03, "90th_percentile": 132.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 66.8, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 66.8, "10th_percentile": 66.8, "90th_percentile": 66.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 91.52, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 91.52, "10th_percentile": 91.52, "90th_percentile": 91.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 182.26, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.26, "10th_percentile": 182.26, "90th_percentile": 182.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 172.0, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 172.0, "10th_percentile": 172.0, "90th_percentile": 172.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 263.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 263.0, "10th_percentile": 263.0, "90th_percentile": 263.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 263.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 263.0, "10th_percentile": 263.0, "90th_percentile": 263.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 49.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 49.97, "10th_percentile": 49.97, "90th_percentile": 49.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 49.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 49.97, "10th_percentile": 49.97, "90th_percentile": 49.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 214.35, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 214.35, "10th_percentile": 214.35, "90th_percentile": 214.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 147.02, "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": 147.02, "10th_percentile": 147.02, "90th_percentile": 147.02, "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": "VWH BCBS HMO", "standard_charge_dollar": 171.34, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 171.34, "10th_percentile": 171.34, "90th_percentile": 171.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 148.2, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 148.2, "10th_percentile": 148.2, "90th_percentile": 148.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 165.98, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.98, "10th_percentile": 165.98, "90th_percentile": 165.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 176.37, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.37, "10th_percentile": 176.37, "90th_percentile": 176.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Chair Pressure Pad Alarm", "code_information": [ { "code": "PX-27105011", "type": "CDM" }, { "code": "27105011", "type": "LOCAL" }, { "code": "0271", "type": "RC" } ], "standard_charges": [ { "minimum": 68.59, "maximum": 361.0, "setting": "outpatient", "gross_charge": 361.0, "discounted_cash": 252.7, "payers_information": [ { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 361.0, "10th_percentile": 361.0, "90th_percentile": 361.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 361.0, "10th_percentile": 361.0, "90th_percentile": 361.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 361.0, "10th_percentile": 361.0, "90th_percentile": 361.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 361.0, "10th_percentile": 361.0, "90th_percentile": 361.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 361.0, "10th_percentile": 361.0, "90th_percentile": 361.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 361.0, "10th_percentile": 361.0, "90th_percentile": 361.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 174.36, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.36, "10th_percentile": 174.36, "90th_percentile": 174.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 163.53, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 163.53, "10th_percentile": 163.53, "90th_percentile": 163.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 294.22, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 294.22, "10th_percentile": 294.22, "90th_percentile": 294.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 235.19, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 235.19, "10th_percentile": 235.19, "90th_percentile": 235.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 196.2, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 196.2, "10th_percentile": 196.2, "90th_percentile": 196.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 243.31, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 243.31, "10th_percentile": 243.31, "90th_percentile": 243.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 270.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 270.75, "10th_percentile": 270.75, "90th_percentile": 270.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 68.59, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 68.59, "10th_percentile": 68.59, "90th_percentile": 68.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 315.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 315.88, "10th_percentile": 315.88, "90th_percentile": 315.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 288.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 288.8, "10th_percentile": 288.8, "90th_percentile": 288.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 162.45, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 162.45, "10th_percentile": 162.45, "90th_percentile": 162.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 306.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 306.85, "10th_percentile": 306.85, "90th_percentile": 306.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 361.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 361.0, "10th_percentile": 361.0, "90th_percentile": 361.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 241.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 241.51, "10th_percentile": 241.51, "90th_percentile": 241.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 181.22, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.22, "10th_percentile": 181.22, "90th_percentile": 181.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 91.69, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 91.69, "10th_percentile": 91.69, "90th_percentile": 91.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 125.63, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 125.63, "10th_percentile": 125.63, "90th_percentile": 125.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 250.17, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.17, "10th_percentile": 250.17, "90th_percentile": 250.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 236.09, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 361.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 361.0, "10th_percentile": 361.0, "90th_percentile": 361.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 361.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 361.0, "10th_percentile": 361.0, "90th_percentile": 361.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 68.59, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 68.59, "10th_percentile": 68.59, "90th_percentile": 68.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 68.59, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 68.59, "10th_percentile": 68.59, "90th_percentile": 68.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 201.8, "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": 201.8, "10th_percentile": 201.8, "90th_percentile": 201.8, "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": "VWH BCBS HMO", "standard_charge_dollar": 235.19, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 235.19, "10th_percentile": 235.19, "90th_percentile": 235.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 227.83, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 227.83, "10th_percentile": 227.83, "90th_percentile": 227.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 242.09, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 242.09, "10th_percentile": 242.09, "90th_percentile": 242.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 294.22, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 294.22, "10th_percentile": 294.22, "90th_percentile": 294.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 203.42, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.42, "10th_percentile": 203.42, "90th_percentile": 203.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Chemo IV Infusion Addl Hr", "code_information": [ { "code": "PX-33500001", "type": "CDM" }, { "code": "96415", "type": "CPT" }, { "code": "0335", "type": "RC" } ], "standard_charges": [ { "minimum": 89.68, "maximum": 472.0, "setting": "outpatient", "gross_charge": 472.0, "discounted_cash": 330.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 285.09, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 285.09, "10th_percentile": 285.09, "90th_percentile": 285.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 285.09, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 285.09, "10th_percentile": 285.09, "90th_percentile": 285.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 307.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 307.51, "10th_percentile": 307.51, "90th_percentile": 307.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 263.85, "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": 263.85, "10th_percentile": 263.85, "90th_percentile": 263.85, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 297.36, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 297.36, "10th_percentile": 297.36, "90th_percentile": 297.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 385.62, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 385.62, "10th_percentile": 385.62, "90th_percentile": 385.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 89.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 89.68, "10th_percentile": 89.68, "90th_percentile": 89.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 89.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 89.68, "10th_percentile": 89.68, "90th_percentile": 89.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 89.68, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 89.68, "10th_percentile": 89.68, "90th_percentile": 89.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 472.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 472.0, "10th_percentile": 472.0, "90th_percentile": 472.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 472.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 472.0, "10th_percentile": 472.0, "90th_percentile": 472.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 308.69, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 308.69, "10th_percentile": 308.69, "90th_percentile": 308.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 119.89, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 119.89, "10th_percentile": 119.89, "90th_percentile": 119.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 327.1, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 327.1, "10th_percentile": 327.1, "90th_percentile": 327.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 164.26, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 164.26, "10th_percentile": 164.26, "90th_percentile": 164.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 472.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 472.0, "10th_percentile": 472.0, "90th_percentile": 472.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 413.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 413.0, "10th_percentile": 413.0, "90th_percentile": 413.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 307.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 307.51, "10th_percentile": 307.51, "90th_percentile": 307.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 256.53, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 256.53, "10th_percentile": 256.53, "90th_percentile": 256.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 318.13, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 318.13, "10th_percentile": 318.13, "90th_percentile": 318.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 354.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 354.0, "10th_percentile": 354.0, "90th_percentile": 354.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 401.2, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 401.2, "10th_percentile": 401.2, "90th_percentile": 401.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 212.4, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 212.4, "10th_percentile": 212.4, "90th_percentile": 212.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 377.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 377.6, "10th_percentile": 377.6, "90th_percentile": 377.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 385.62, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 385.62, "10th_percentile": 385.62, "90th_percentile": 385.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 236.94, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 236.94, "10th_percentile": 236.94, "90th_percentile": 236.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 315.77, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 315.77, "10th_percentile": 315.77, "90th_percentile": 315.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 227.98, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Chemotherapy; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 227.98, "10th_percentile": 227.98, "90th_percentile": 227.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Chemotherapy; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 213.82, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Chemotherapy; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 213.82, "10th_percentile": 213.82, "90th_percentile": 213.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Chemotherapy; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Chemodenervation Trunk 6 or More Muscles", "code_information": [ { "code": "PX-76100012", "type": "CDM" }, { "code": "64647", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 1310.72, "maximum": 2611.0, "setting": "outpatient", "gross_charge": 2611.0, "discounted_cash": 1827.7, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2611.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2611.0, "10th_percentile": 2611.0, "90th_percentile": 2611.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1310.72, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1310.72, "10th_percentile": 1310.72, "90th_percentile": 1310.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1746.76, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1746.76, "10th_percentile": 1746.76, "90th_percentile": 1746.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Closed Tx Nasal Bone Fx W/Mnpj W/Stabilization", "code_information": [ { "code": "PX-36100202", "type": "CDM" }, { "code": "21320", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 2718.33, "maximum": 5415.0, "setting": "outpatient", "gross_charge": 5415.0, "discounted_cash": 3790.5, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5415.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5415.0, "10th_percentile": 5415.0, "90th_percentile": 5415.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2718.33, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2718.33, "10th_percentile": 2718.33, "90th_percentile": 2718.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3622.64, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3622.64, "10th_percentile": 3622.64, "90th_percentile": 3622.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Closure of Split Wound Simple With Packing", "code_information": [ { "code": "PX-36100089", "type": "CDM" }, { "code": "12021", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 1213.33, "maximum": 2417.0, "setting": "outpatient", "gross_charge": 2417.0, "discounted_cash": 1691.9, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2417.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2417.0, "10th_percentile": 2417.0, "90th_percentile": 2417.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1213.33, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1213.33, "10th_percentile": 1213.33, "90th_percentile": 1213.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1616.97, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1616.97, "10th_percentile": 1616.97, "90th_percentile": 1616.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Cltx Dstl Fem Epiphysl Sep W/Manj W/WO Skin/Skel", "code_information": [ { "code": "PX-76100223", "type": "CDM" }, { "code": "27517", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 796.1, "maximum": 4190.0, "setting": "outpatient", "gross_charge": 4190.0, "discounted_cash": 2933.0, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2342.21, "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": 2342.21, "10th_percentile": 2342.21, "90th_percentile": 2342.21, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1898.07, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1898.07, "10th_percentile": 1898.07, "90th_percentile": 1898.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2023.77, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2023.77, "10th_percentile": 2023.77, "90th_percentile": 2023.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 3561.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 3561.5, "10th_percentile": 3561.5, "90th_percentile": 3561.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3142.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 3142.5, "10th_percentile": 3142.5, "90th_percentile": 3142.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2277.27, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2277.27, "10th_percentile": 2277.27, "90th_percentile": 2277.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2824.06, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2824.06, "10th_percentile": 2824.06, "90th_percentile": 2824.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 3666.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 3666.25, "10th_percentile": 3666.25, "90th_percentile": 3666.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 3352.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 3352.0, "10th_percentile": 3352.0, "90th_percentile": 3352.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1885.5, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1885.5, "10th_percentile": 1885.5, "90th_percentile": 1885.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 796.1, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 796.1, "10th_percentile": 796.1, "90th_percentile": 796.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 796.1, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 796.1, "10th_percentile": 796.1, "90th_percentile": 796.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1064.26, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1064.26, "10th_percentile": 1064.26, "90th_percentile": 1064.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1458.12, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1458.12, "10th_percentile": 1458.12, "90th_percentile": 1458.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2903.67, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2903.67, "10th_percentile": 2903.67, "90th_percentile": 2903.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2740.26, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2740.26, "10th_percentile": 2740.26, "90th_percentile": 2740.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 796.1, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 796.1, "10th_percentile": 796.1, "90th_percentile": 796.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4190.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4190.0, "10th_percentile": 4190.0, "90th_percentile": 4190.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4190.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4190.0, "10th_percentile": 4190.0, "90th_percentile": 4190.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 2729.79, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2729.79, "10th_percentile": 2729.79, "90th_percentile": 2729.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2729.79, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2729.79, "10th_percentile": 2729.79, "90th_percentile": 2729.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Cltx Phlngl Fx Prox/Middle Px/F/T W/O Manj Ea", "code_information": [ { "code": "PX-36100263", "type": "CDM" }, { "code": "26720", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 436.74, "maximum": 870.0, "setting": "outpatient", "gross_charge": 870.0, "discounted_cash": 609.0, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 870.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 870.0, "10th_percentile": 870.0, "90th_percentile": 870.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 436.74, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.74, "10th_percentile": 436.74, "90th_percentile": 436.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 582.03, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 582.03, "10th_percentile": 582.03, "90th_percentile": 582.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Cmplx Rpr E/N/E/L 2.6-7.5 Cm", "code_information": [ { "code": "PX-36100114", "type": "CDM" }, { "code": "13152", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 429.97, "maximum": 2263.0, "setting": "outpatient", "gross_charge": 2263.0, "discounted_cash": 1584.1, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1265.02, "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": 1265.02, "10th_percentile": 1265.02, "90th_percentile": 1265.02, "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": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1025.14, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1025.14, "10th_percentile": 1025.14, "90th_percentile": 1025.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1093.03, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1093.03, "10th_percentile": 1093.03, "90th_percentile": 1093.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 1923.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1923.55, "10th_percentile": 1923.55, "90th_percentile": 1923.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1697.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1697.25, "10th_percentile": 1697.25, "90th_percentile": 1697.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1229.94, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1229.94, "10th_percentile": 1229.94, "90th_percentile": 1229.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1525.26, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1525.26, "10th_percentile": 1525.26, "90th_percentile": 1525.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1980.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1980.13, "10th_percentile": 1980.13, "90th_percentile": 1980.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1810.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1810.4, "10th_percentile": 1810.4, "90th_percentile": 1810.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1018.35, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1018.35, "10th_percentile": 1018.35, "90th_percentile": 1018.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 429.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 429.97, "10th_percentile": 429.97, "90th_percentile": 429.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 429.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 429.97, "10th_percentile": 429.97, "90th_percentile": 429.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 574.8, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 574.8, "10th_percentile": 574.8, "90th_percentile": 574.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 787.52, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 787.52, "10th_percentile": 787.52, "90th_percentile": 787.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1568.26, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1568.26, "10th_percentile": 1568.26, "90th_percentile": 1568.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1480.0, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1480.0, "10th_percentile": 1480.0, "90th_percentile": 1480.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 429.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 429.97, "10th_percentile": 429.97, "90th_percentile": 429.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2263.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2263.0, "10th_percentile": 2263.0, "90th_percentile": 2263.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2263.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2263.0, "10th_percentile": 2263.0, "90th_percentile": 2263.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 1474.34, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1474.34, "10th_percentile": 1474.34, "90th_percentile": 1474.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1474.34, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1474.34, "10th_percentile": 1474.34, "90th_percentile": 1474.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Cmv, Pcr", "code_information": [ { "code": "PX-30614675", "type": "CDM" }, { "code": "87496", "type": "CPT" }, { "code": "0306", "type": "RC" } ], "standard_charges": [ { "minimum": 69.92, "maximum": 368.0, "setting": "outpatient", "gross_charge": 368.0, "discounted_cash": 257.6, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 368.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 368.0, "10th_percentile": 368.0, "90th_percentile": 368.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 368.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 368.0, "10th_percentile": 368.0, "90th_percentile": 368.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 300.66, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 300.66, "10th_percentile": 300.66, "90th_percentile": 300.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 165.6, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 165.6, "10th_percentile": 165.6, "90th_percentile": 165.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 248.03, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 248.03, "10th_percentile": 248.03, "90th_percentile": 248.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 322.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 322.0, "10th_percentile": 322.0, "90th_percentile": 322.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 312.8, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 312.8, "10th_percentile": 312.8, "90th_percentile": 312.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 239.75, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 239.75, "10th_percentile": 239.75, "90th_percentile": 239.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 368.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 368.0, "10th_percentile": 368.0, "90th_percentile": 368.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 200.01, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 200.01, "10th_percentile": 200.01, "90th_percentile": 200.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 294.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 294.4, "10th_percentile": 294.4, "90th_percentile": 294.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 276.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 276.0, "10th_percentile": 276.0, "90th_percentile": 276.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 255.02, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 255.02, "10th_percentile": 255.02, "90th_percentile": 255.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 128.06, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 128.06, "10th_percentile": 128.06, "90th_percentile": 128.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 93.47, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 93.47, "10th_percentile": 93.47, "90th_percentile": 93.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 300.66, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 300.66, "10th_percentile": 300.66, "90th_percentile": 300.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 231.84, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 231.84, "10th_percentile": 231.84, "90th_percentile": 231.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 239.75, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 239.75, "10th_percentile": 239.75, "90th_percentile": 239.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 205.71, "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": 205.71, "10th_percentile": 205.71, "90th_percentile": 205.71, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 222.27, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 222.27, "10th_percentile": 222.27, "90th_percentile": 222.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 222.27, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 222.27, "10th_percentile": 222.27, "90th_percentile": 222.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 69.92, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 69.92, "10th_percentile": 69.92, "90th_percentile": 69.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 69.92, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 69.92, "10th_percentile": 69.92, "90th_percentile": 69.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 69.92, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 69.92, "10th_percentile": 69.92, "90th_percentile": 69.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Colonoscopy W Endoscopic Full-Thickness Resection (Eftr) - Unlisted", "code_information": [ { "code": "PX-75000372", "type": "CDM" }, { "code": "45399", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 169.12, "maximum": 2451.0, "setting": "outpatient", "gross_charge": 2451.0, "discounted_cash": 1715.7, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 465.69, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 465.69, "10th_percentile": 465.69, "90th_percentile": 465.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 465.69, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 465.69, "10th_percentile": 465.69, "90th_percentile": 465.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 465.69, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 465.69, "10th_percentile": 465.69, "90th_percentile": 465.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2002.47, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2002.47, "10th_percentile": 2002.47, "90th_percentile": 2002.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1110.3, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1110.3, "10th_percentile": 1110.3, "90th_percentile": 1110.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1183.83, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1183.83, "10th_percentile": 1183.83, "90th_percentile": 1183.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1596.83, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1596.83, "10th_percentile": 1596.83, "90th_percentile": 1596.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1838.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1838.25, "10th_percentile": 1838.25, "90th_percentile": 1838.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1651.97, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1651.97, "10th_percentile": 1651.97, "90th_percentile": 1651.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2144.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2144.63, "10th_percentile": 2144.63, "90th_percentile": 2144.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1332.12, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1332.12, "10th_percentile": 1332.12, "90th_percentile": 1332.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1102.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1102.95, "10th_percentile": 1102.95, "90th_percentile": 1102.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 2083.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2083.35, "10th_percentile": 2083.35, "90th_percentile": 2083.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2083.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 2083.35, "10th_percentile": 2083.35, "90th_percentile": 2083.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 169.12, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 169.12, "10th_percentile": 169.12, "90th_percentile": 169.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 169.12, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 169.12, "10th_percentile": 169.12, "90th_percentile": 169.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 169.12, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 169.12, "10th_percentile": 169.12, "90th_percentile": 169.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 169.12, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 169.12, "10th_percentile": 169.12, "90th_percentile": 169.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 169.12, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 169.12, "10th_percentile": 169.12, "90th_percentile": 169.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 169.12, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 169.12, "10th_percentile": 169.12, "90th_percentile": 169.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2451.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2451.0, "10th_percentile": 2451.0, "90th_percentile": 2451.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1230.4, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1230.4, "10th_percentile": 1230.4, "90th_percentile": 1230.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1639.72, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1639.72, "10th_percentile": 1639.72, "90th_percentile": 1639.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1698.54, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1698.54, "10th_percentile": 1698.54, "90th_percentile": 1698.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1602.95, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1602.95, "10th_percentile": 1602.95, "90th_percentile": 1602.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 852.95, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 852.95, "10th_percentile": 852.95, "90th_percentile": 852.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 622.55, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 622.55, "10th_percentile": 622.55, "90th_percentile": 622.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2451.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2451.0, "10th_percentile": 2451.0, "90th_percentile": 2451.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2451.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2451.0, "10th_percentile": 2451.0, "90th_percentile": 2451.0, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1480.4, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1480.4, "10th_percentile": 1480.4, "90th_percentile": 1480.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1480.4, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1480.4, "10th_percentile": 1480.4, "90th_percentile": 1480.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1370.11, "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": 1370.11, "10th_percentile": 1370.11, "90th_percentile": 1370.11, "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1596.83, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1596.83, "10th_percentile": 1596.83, "90th_percentile": 1596.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2002.47, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2002.47, "10th_percentile": 2002.47, "90th_percentile": 2002.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1544.13, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1544.13, "10th_percentile": 1544.13, "90th_percentile": 1544.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Colonoscopy W/Biopsy Single/Multiple", "code_information": [ { "code": "PX-75000103", "type": "CDM" }, { "code": "45380", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 1111.31, "maximum": 5849.0, "setting": "outpatient", "gross_charge": 5849.0, "discounted_cash": 4094.3, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1485.65, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1614.32, "10th_percentile": 1614.32, "90th_percentile": 1614.32, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2035.45, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 4152.57, "10th_percentile": 4152.57, "90th_percentile": 4152.57, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2936.2, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5567.31, "10th_percentile": 5567.31, "90th_percentile": 5567.31, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1111.31, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1111.31, "10th_percentile": 1111.31, "90th_percentile": 1111.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1111.31, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1111.31, "10th_percentile": 1111.31, "90th_percentile": 1111.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1111.31, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1111.31, "10th_percentile": 1111.31, "90th_percentile": 1111.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4778.63, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4778.63, "10th_percentile": 4778.63, "90th_percentile": 4778.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2649.6, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2649.6, "10th_percentile": 2649.6, "90th_percentile": 2649.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2825.07, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2825.07, "10th_percentile": 2825.07, "90th_percentile": 2825.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3810.62, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3810.62, "10th_percentile": 3810.62, "90th_percentile": 3810.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4386.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4386.75, "10th_percentile": 4386.75, "90th_percentile": 4386.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3942.23, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3942.23, "10th_percentile": 3942.23, "90th_percentile": 3942.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 5117.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 5117.88, "10th_percentile": 5117.88, "90th_percentile": 5117.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3178.93, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3178.93, "10th_percentile": 3178.93, "90th_percentile": 3178.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2632.05, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2632.05, "10th_percentile": 2632.05, "90th_percentile": 2632.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 4971.65, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4971.65, "10th_percentile": 4971.65, "90th_percentile": 4971.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4971.65, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 4971.65, "10th_percentile": 4971.65, "90th_percentile": 4971.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5849.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5849.0, "10th_percentile": 5849.0, "90th_percentile": 5849.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3912.98, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3912.98, "10th_percentile": 3912.98, "90th_percentile": 3912.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 4053.36, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4053.36, "10th_percentile": 4053.36, "90th_percentile": 4053.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3825.25, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3825.25, "10th_percentile": 3825.25, "90th_percentile": 3825.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5849.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5849.0, "10th_percentile": 5849.0, "90th_percentile": 5849.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5849.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5849.0, "10th_percentile": 5849.0, "90th_percentile": 5849.0, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3532.8, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3532.8, "10th_percentile": 3532.8, "90th_percentile": 3532.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3532.8, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3532.8, "10th_percentile": 3532.8, "90th_percentile": 3532.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3269.59, "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": 3269.59, "10th_percentile": 3269.59, "90th_percentile": 3269.59, "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": "VWH BCBS HMO", "standard_charge_dollar": 3810.62, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3810.62, "10th_percentile": 3810.62, "90th_percentile": 3810.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4778.63, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4778.63, "10th_percentile": 4778.63, "90th_percentile": 4778.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3684.87, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3684.87, "10th_percentile": 3684.87, "90th_percentile": 3684.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Colsc Flexible W/Transendoscopic Balloon Dilat", "code_information": [ { "code": "CASE-45386", "type": "LOCAL" }, { "code": "45386", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 108.86, "maximum": 108.86, "setting": "outpatient", "gross_charge": 28747.26, "discounted_cash": 20123.08, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 60.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 17363.36, "10th_percentile": 17363.36, "90th_percentile": 17363.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 18110.78, "10th_percentile": 18110.78, "90th_percentile": 18110.78, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 60.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 17363.36, "10th_percentile": 17363.36, "90th_percentile": 17363.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 18728.83, "10th_percentile": 18728.83, "90th_percentile": 18728.83, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": 16069.72, "10th_percentile": 16069.72, "90th_percentile": 16069.72, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 81.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 23486.5, "10th_percentile": 23486.5, "90th_percentile": 23486.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19375.67, "10th_percentile": 19375.67, "90th_percentile": 19375.67, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 12696.58, "10th_percentile": 12696.58, "90th_percentile": 12696.58, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 13536.73, "10th_percentile": 13536.73, "90th_percentile": 13536.73, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH 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": 28747.26, "10th_percentile": 28747.26, "90th_percentile": 28747.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 5461.99, "10th_percentile": 5461.99, "90th_percentile": 5461.99, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 24435.18, "10th_percentile": 24435.18, "90th_percentile": 24435.18, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_percentage": 45.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 12936.27, "10th_percentile": 12936.27, "90th_percentile": 12936.27, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 21560.47, "10th_percentile": 21560.47, "90th_percentile": 21560.47, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_percentage": 87.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 25153.87, "10th_percentile": 25153.87, "90th_percentile": 25153.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH 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": 28747.26, "10th_percentile": 28747.26, "90th_percentile": 28747.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 23912.9, "10th_percentile": 23912.9, "90th_percentile": 23912.9, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 15624.14, "10th_percentile": 15624.14, "90th_percentile": 15624.14, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 14071.05, "10th_percentile": 14071.05, "90th_percentile": 14071.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 18747.92, "10th_percentile": 18747.92, "90th_percentile": 18747.92, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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": 28747.26, "10th_percentile": 28747.26, "90th_percentile": 28747.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 18800.73, "10th_percentile": 18800.73, "90th_percentile": 18800.73, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19921.85, "10th_percentile": 19921.85, "90th_percentile": 19921.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_percentage": 34.8, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 10004.04, "10th_percentile": 10004.04, "90th_percentile": 10004.04, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_percentage": 25.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 7301.82, "10th_percentile": 7301.82, "90th_percentile": 7301.82, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 5461.99, "10th_percentile": 5461.99, "90th_percentile": 5461.99, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 18728.83, "10th_percentile": 18728.83, "90th_percentile": 18728.83, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 81.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 23486.5, "10th_percentile": 23486.5, "90th_percentile": 23486.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 5461.99, "10th_percentile": 5461.99, "90th_percentile": 5461.99, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 108.86, "standard_charge_algorithm": "Re-evaluated: HLB.792021995; Using new claim; Scope: All Financial Classes; Cases: 1; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 108.86, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1305.77, "10th_percentile": 1305.77, "90th_percentile": 1305.77, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 108.86, "standard_charge_algorithm": "Re-evaluated: HLB.792021995; Using new claim; Scope: All Financial Classes; Cases: 1; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 108.86, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1305.77, "10th_percentile": 1305.77, "90th_percentile": 1305.77, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 108.86, "standard_charge_algorithm": "Re-evaluated: HLB.792021995; Using new claim; Scope: All Financial Classes; Cases: 1; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 108.86, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1305.77, "10th_percentile": 1305.77, "90th_percentile": 1305.77, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 108.86, "standard_charge_algorithm": "Re-evaluated: HLB.792021995; Using new claim; Scope: All Financial Classes; Cases: 1; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 108.86, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1305.77, "10th_percentile": 1305.77, "90th_percentile": 1305.77, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 108.86, "standard_charge_algorithm": "Re-evaluated: HLB.792021995; Using new claim; Scope: All Financial Classes; Cases: 1; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 108.86, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1305.77, "10th_percentile": 1305.77, "90th_percentile": 1305.77, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 108.86, "standard_charge_algorithm": "Re-evaluated: HLB.792021995; Using new claim; Scope: All Financial Classes; Cases: 1; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 108.86, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1305.77, "10th_percentile": 1305.77, "90th_percentile": 1305.77, "count": "1 through 10", "methodology": "fee schedule" } ] } ] }, { "description": "HB Colsc Flexible W/Transendoscopic Balloon Dilat", "code_information": [ { "code": "PX-75000108", "type": "CDM" }, { "code": "45386", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 1254.76, "maximum": 6604.0, "setting": "outpatient", "gross_charge": 6604.0, "discounted_cash": 4622.8, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1254.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1254.76, "10th_percentile": 1254.76, "90th_percentile": 1254.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1254.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1254.76, "10th_percentile": 1254.76, "90th_percentile": 1254.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1254.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1254.76, "10th_percentile": 1254.76, "90th_percentile": 1254.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 5395.47, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5395.47, "10th_percentile": 5395.47, "90th_percentile": 5395.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2991.61, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2991.61, "10th_percentile": 2991.61, "90th_percentile": 2991.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 3189.73, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3189.73, "10th_percentile": 3189.73, "90th_percentile": 3189.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 4302.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4302.51, "10th_percentile": 4302.51, "90th_percentile": 4302.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4953.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4953.0, "10th_percentile": 4953.0, "90th_percentile": 4953.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 4451.1, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 4451.1, "10th_percentile": 4451.1, "90th_percentile": 4451.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 5778.5, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 5778.5, "10th_percentile": 5778.5, "90th_percentile": 5778.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3589.27, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3589.27, "10th_percentile": 3589.27, "90th_percentile": 3589.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2971.8, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2971.8, "10th_percentile": 2971.8, "90th_percentile": 2971.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 5613.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 5613.4, "10th_percentile": 5613.4, "90th_percentile": 5613.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 5613.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 5613.4, "10th_percentile": 5613.4, "90th_percentile": 5613.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6604.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6604.0, "10th_percentile": 6604.0, "90th_percentile": 6604.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 3315.21, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3315.21, "10th_percentile": 3315.21, "90th_percentile": 3315.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 4418.08, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4418.08, "10th_percentile": 4418.08, "90th_percentile": 4418.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 4576.57, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4576.57, "10th_percentile": 4576.57, "90th_percentile": 4576.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 4319.02, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4319.02, "10th_percentile": 4319.02, "90th_percentile": 4319.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2298.19, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2298.19, "10th_percentile": 2298.19, "90th_percentile": 2298.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1677.42, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1677.42, "10th_percentile": 1677.42, "90th_percentile": 1677.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6604.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6604.0, "10th_percentile": 6604.0, "90th_percentile": 6604.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6604.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6604.0, "10th_percentile": 6604.0, "90th_percentile": 6604.0, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3988.82, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3988.82, "10th_percentile": 3988.82, "90th_percentile": 3988.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3988.82, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3988.82, "10th_percentile": 3988.82, "90th_percentile": 3988.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3691.64, "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": 3691.64, "10th_percentile": 3691.64, "90th_percentile": 3691.64, "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": "VWH BCBS HMO", "standard_charge_dollar": 4302.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4302.51, "10th_percentile": 4302.51, "90th_percentile": 4302.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 5395.47, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5395.47, "10th_percentile": 5395.47, "90th_percentile": 5395.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4160.52, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4160.52, "10th_percentile": 4160.52, "90th_percentile": 4160.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Complement: C3", "code_information": [ { "code": "PX-30209155", "type": "CDM" }, { "code": "86160", "type": "CPT" }, { "code": "0302", "type": "RC" } ], "standard_charges": [ { "minimum": 29.26, "maximum": 154.0, "setting": "outpatient", "gross_charge": 154.0, "discounted_cash": 107.8, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 154.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 154.0, "10th_percentile": 154.0, "90th_percentile": 154.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 154.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 154.0, "10th_percentile": 154.0, "90th_percentile": 154.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 125.82, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 125.82, "10th_percentile": 125.82, "90th_percentile": 125.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 134.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 134.75, "10th_percentile": 134.75, "90th_percentile": 134.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 130.9, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 130.9, "10th_percentile": 130.9, "90th_percentile": 130.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 100.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 100.33, "10th_percentile": 100.33, "90th_percentile": 100.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 154.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 154.0, "10th_percentile": 154.0, "90th_percentile": 154.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 115.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 115.5, "10th_percentile": 115.5, "90th_percentile": 115.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 103.8, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 103.8, "10th_percentile": 103.8, "90th_percentile": 103.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 123.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 123.2, "10th_percentile": 123.2, "90th_percentile": 123.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 83.7, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 83.7, "10th_percentile": 83.7, "90th_percentile": 83.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 69.3, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 69.3, "10th_percentile": 69.3, "90th_percentile": 69.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 106.72, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.72, "10th_percentile": 106.72, "90th_percentile": 106.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 53.59, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 53.59, "10th_percentile": 53.59, "90th_percentile": 53.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 39.12, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 39.12, "10th_percentile": 39.12, "90th_percentile": 39.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 125.82, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 125.82, "10th_percentile": 125.82, "90th_percentile": 125.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 97.02, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.02, "10th_percentile": 97.02, "90th_percentile": 97.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 86.09, "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": 86.09, "10th_percentile": 86.09, "90th_percentile": 86.09, "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": "VWH BCBS HMO", "standard_charge_dollar": 100.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 100.33, "10th_percentile": 100.33, "90th_percentile": 100.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 93.02, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.02, "10th_percentile": 93.02, "90th_percentile": 93.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 93.02, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.02, "10th_percentile": 93.02, "90th_percentile": 93.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 29.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.77, "10th_percentile": 28.77, "90th_percentile": 28.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 29.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 29.26, "10th_percentile": 29.26, "90th_percentile": 29.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 29.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 29.26, "10th_percentile": 29.26, "90th_percentile": 29.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Coronary Artery Angio S&I", "code_information": [ { "code": "PX-48100072", "type": "CDM" }, { "code": "93454", "type": "CPT" }, { "code": "0481", "type": "RC" } ], "standard_charges": [ { "minimum": 4017.74, "maximum": 21146.0, "setting": "outpatient", "gross_charge": 21146.0, "discounted_cash": 14802.2, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 13776.62, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 13776.62, "10th_percentile": 13776.62, "90th_percentile": 13776.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 12095.51, "standard_charge_percentage": 57.2, "standard_charge_algorithm": "OP Surgery. ADP RATE (for patient estimates only); 57.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12095.51, "10th_percentile": 12095.51, "90th_percentile": 12095.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery. ADP RATE (for patient estimates only); 57.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 16218.98, "standard_charge_percentage": 76.7, "standard_charge_algorithm": "OP Surgery. ADP RATE (for patient estimates only); 76.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16218.98, "10th_percentile": 16218.98, "90th_percentile": 16218.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery. ADP RATE (for patient estimates only); 76.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 11820.61, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "OP Surgery. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11820.61, "10th_percentile": 11820.61, "90th_percentile": 11820.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 12201.24, "standard_charge_percentage": 57.7, "standard_charge_algorithm": "OP Surgery. ADP RATE (for patient estimates only); 57.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12201.24, "10th_percentile": 12201.24, "90th_percentile": 12201.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery. ADP RATE (for patient estimates only); 57.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 12201.24, "standard_charge_percentage": 57.7, "standard_charge_algorithm": "OP Surgery. ADP RATE (for patient estimates only); 57.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12201.24, "10th_percentile": 12201.24, "90th_percentile": 12201.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery. ADP RATE (for patient estimates only); 57.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 4017.74, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 4017.74, "10th_percentile": 4017.74, "90th_percentile": 4017.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 4017.74, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 4017.74, "10th_percentile": 4017.74, "90th_percentile": 4017.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 4017.74, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 4017.74, "10th_percentile": 4017.74, "90th_percentile": 4017.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 21146.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 21146.0, "10th_percentile": 21146.0, "90th_percentile": 21146.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 21146.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 21146.0, "10th_percentile": 21146.0, "90th_percentile": 21146.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 13829.48, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13829.48, "10th_percentile": 13829.48, "90th_percentile": 13829.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 14654.18, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14654.18, "10th_percentile": 14654.18, "90th_percentile": 14654.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 5371.08, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 5371.08, "10th_percentile": 5371.08, "90th_percentile": 5371.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 7358.81, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 7358.81, "10th_percentile": 7358.81, "90th_percentile": 7358.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 21146.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 21146.0, "10th_percentile": 21146.0, "90th_percentile": 21146.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 18502.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 18502.75, "10th_percentile": 18502.75, "90th_percentile": 18502.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 13776.62, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 13776.62, "10th_percentile": 13776.62, "90th_percentile": 13776.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 11492.85, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 11492.85, "10th_percentile": 11492.85, "90th_percentile": 11492.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 14252.4, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 14252.4, "10th_percentile": 14252.4, "90th_percentile": 14252.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 15859.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 15859.5, "10th_percentile": 15859.5, "90th_percentile": 15859.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 17974.1, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 17974.1, "10th_percentile": 17974.1, "90th_percentile": 17974.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 9515.7, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 9515.7, "10th_percentile": 9515.7, "90th_percentile": 9515.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 16916.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 16916.8, "10th_percentile": 16916.8, "90th_percentile": 16916.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 14146.67, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14146.67, "10th_percentile": 14146.67, "90th_percentile": 14146.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 10615.29, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10615.29, "10th_percentile": 10615.29, "90th_percentile": 10615.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 10213.52, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Cardiac CathLab; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10213.52, "10th_percentile": 10213.52, "90th_percentile": 10213.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Cardiac CathLab; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 9579.14, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Cardiac CathLab; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9579.14, "10th_percentile": 9579.14, "90th_percentile": 9579.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Cardiac CathLab; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 16218.98, "standard_charge_percentage": 76.7, "standard_charge_algorithm": "OP Surgery. ADP RATE (for patient estimates only); 76.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16218.98, "10th_percentile": 16218.98, "90th_percentile": 16218.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery. ADP RATE (for patient estimates only); 76.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Cortisol Level 60 Minutes Post-Stim", "code_information": [ { "code": "PX-30105197", "type": "CDM" }, { "code": "82533", "type": "CPT" }, { "code": "0301", "type": "RC" } ], "standard_charges": [ { "minimum": 37.24, "maximum": 196.0, "setting": "outpatient", "gross_charge": 196.0, "discounted_cash": 137.2, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 49.78, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 51.62, "10th_percentile": 51.62, "90th_percentile": 51.62, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 118.38, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 118.38, "10th_percentile": 118.38, "90th_percentile": 118.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 118.38, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 118.38, "10th_percentile": 118.38, "90th_percentile": 118.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 127.69, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 127.69, "10th_percentile": 127.69, "90th_percentile": 127.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 109.56, "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": 109.56, "10th_percentile": 109.56, "90th_percentile": 109.56, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 123.48, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.48, "10th_percentile": 123.48, "90th_percentile": 123.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 160.13, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 166.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 166.6, "10th_percentile": 166.6, "90th_percentile": 166.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 196.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 196.0, "10th_percentile": 196.0, "90th_percentile": 196.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 156.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 156.8, "10th_percentile": 156.8, "90th_percentile": 156.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 88.2, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% 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 OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 132.1, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 132.1, "10th_percentile": 132.1, "90th_percentile": 132.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 147.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 147.0, "10th_percentile": 147.0, "90th_percentile": 147.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 171.5, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 171.5, "10th_percentile": 171.5, "90th_percentile": 171.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 106.53, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 106.53, "10th_percentile": 106.53, "90th_percentile": 106.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 127.69, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 127.69, "10th_percentile": 127.69, "90th_percentile": 127.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 160.13, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 68.21, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 68.21, "10th_percentile": 68.21, "90th_percentile": 68.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 135.83, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.83, "10th_percentile": 135.83, "90th_percentile": 135.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 196.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 196.0, "10th_percentile": 196.0, "90th_percentile": 196.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 196.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 196.0, "10th_percentile": 196.0, "90th_percentile": 196.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 37.24, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 37.24, "10th_percentile": 37.24, "90th_percentile": 37.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 37.24, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 37.24, "10th_percentile": 37.24, "90th_percentile": 37.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 37.24, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 37.24, "10th_percentile": 37.24, "90th_percentile": 37.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Critical Care First Hour", "code_information": [ { "code": "PX-45000135", "type": "CDM" }, { "code": "99291", "type": "CPT" }, { "code": "0450", "type": "RC" } ], "standard_charges": [ { "minimum": 958.55, "maximum": 5045.0, "setting": "outpatient", "gross_charge": 5045.0, "discounted_cash": 3531.5, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3286.82, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3286.82, "10th_percentile": 3286.82, "90th_percentile": 3286.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2820.16, "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": 2820.16, "10th_percentile": 2820.16, "90th_percentile": 2820.16, "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": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 958.55, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 958.55, "10th_percentile": 958.55, "90th_percentile": 958.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5045.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5045.0, "10th_percentile": 5045.0, "90th_percentile": 5045.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5045.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5045.0, "10th_percentile": 5045.0, "90th_percentile": 5045.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3299.43, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3299.43, "10th_percentile": 3299.43, "90th_percentile": 3299.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1281.43, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1281.43, "10th_percentile": 1281.43, "90th_percentile": 1281.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3496.19, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3496.19, "10th_percentile": 3496.19, "90th_percentile": 3496.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1755.66, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1755.66, "10th_percentile": 1755.66, "90th_percentile": 1755.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4414.38, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4414.38, "10th_percentile": 4414.38, "90th_percentile": 4414.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3286.82, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3286.82, "10th_percentile": 3286.82, "90th_percentile": 3286.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2741.96, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2741.96, "10th_percentile": 2741.96, "90th_percentile": 2741.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3400.33, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3400.33, "10th_percentile": 3400.33, "90th_percentile": 3400.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3783.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 3783.75, "10th_percentile": 3783.75, "90th_percentile": 3783.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 4288.25, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4288.25, "10th_percentile": 4288.25, "90th_percentile": 4288.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2270.25, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2270.25, "10th_percentile": 2270.25, "90th_percentile": 2270.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4036.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 4036.0, "10th_percentile": 4036.0, "90th_percentile": 4036.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2436.74, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Emergency Room; 48.3% Billed, and; Pricing Extension - NM HB XR PRC - PERCENT OF CHARGES NTE $11,690 EXCLUDING CAR*", "median_amount": 2436.74, "10th_percentile": 2436.74, "90th_percentile": 2436.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Emergency Room; 48.3% Billed, and; Pricing Extension - NM HB XR PRC - PERCENT OF CHARGES NTE $11,690 EXCLUDING CAR*" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2285.39, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Emergency Room; 45.3% Billed, and; Pricing Extension - NM HB XR PRC - PERCENT OF CHARGES NTE $2,900 EXCLUDING CARV*", "median_amount": 2285.39, "10th_percentile": 2285.39, "90th_percentile": 2285.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Emergency Room; 45.3% Billed, and; Pricing Extension - NM HB XR PRC - PERCENT OF CHARGES NTE $2,900 EXCLUDING CARV*" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 958.55, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 958.55, "10th_percentile": 958.55, "90th_percentile": 958.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 958.55, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 958.55, "10th_percentile": 958.55, "90th_percentile": 958.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Crossmatch Incubated Each Unit", "code_information": [ { "code": "PX-30208340", "type": "CDM" }, { "code": "86921", "type": "CPT" }, { "code": "0302", "type": "RC" } ], "standard_charges": [ { "minimum": 34.01, "maximum": 179.0, "setting": "outpatient", "gross_charge": 179.0, "discounted_cash": 125.3, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 179.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 179.0, "10th_percentile": 179.0, "90th_percentile": 179.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 179.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 179.0, "10th_percentile": 179.0, "90th_percentile": 179.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 146.24, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 156.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 156.63, "10th_percentile": 156.63, "90th_percentile": 156.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 152.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 152.15, "10th_percentile": 152.15, "90th_percentile": 152.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 116.62, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 116.62, "10th_percentile": 116.62, "90th_percentile": 116.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 179.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 179.0, "10th_percentile": 179.0, "90th_percentile": 179.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 134.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 134.25, "10th_percentile": 134.25, "90th_percentile": 134.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 120.65, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 120.65, "10th_percentile": 120.65, "90th_percentile": 120.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 143.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 143.2, "10th_percentile": 143.2, "90th_percentile": 143.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 97.29, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 97.29, "10th_percentile": 97.29, "90th_percentile": 97.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 80.55, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 80.55, "10th_percentile": 80.55, "90th_percentile": 80.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 124.05, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.05, "10th_percentile": 124.05, "90th_percentile": 124.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 62.29, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 62.29, "10th_percentile": 62.29, "90th_percentile": 62.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 45.47, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 146.24, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 112.77, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.77, "10th_percentile": 112.77, "90th_percentile": 112.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 100.06, "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": 100.06, "10th_percentile": 100.06, "90th_percentile": 100.06, "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": "VWH BCBS HMO", "standard_charge_dollar": 116.62, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 116.62, "10th_percentile": 116.62, "90th_percentile": 116.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 108.12, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 108.12, "10th_percentile": 108.12, "90th_percentile": 108.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 108.12, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 108.12, "10th_percentile": 108.12, "90th_percentile": 108.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 34.01, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 34.01, "10th_percentile": 34.01, "90th_percentile": 34.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 34.01, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 34.01, "10th_percentile": 34.01, "90th_percentile": 34.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 34.01, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 34.01, "10th_percentile": 34.01, "90th_percentile": 34.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Cystatin C Egfr", "code_information": [ { "code": "PX-30105229", "type": "CDM" }, { "code": "82610", "type": "CPT" }, { "code": "0301", "type": "RC" } ], "standard_charges": [ { "minimum": 28.31, "maximum": 149.0, "setting": "outpatient", "gross_charge": 149.0, "discounted_cash": 104.3, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 90.0, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.0, "10th_percentile": 90.0, "90th_percentile": 90.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 90.0, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.0, "10th_percentile": 90.0, "90th_percentile": 90.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 97.07, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 97.07, "10th_percentile": 97.07, "90th_percentile": 97.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 83.29, "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": 83.29, "10th_percentile": 83.29, "90th_percentile": 83.29, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 93.87, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 121.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.73, "10th_percentile": 121.73, "90th_percentile": 121.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 126.65, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 126.65, "10th_percentile": 126.65, "90th_percentile": 126.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 149.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 149.0, "10th_percentile": 149.0, "90th_percentile": 149.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 119.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 119.2, "10th_percentile": 119.2, "90th_percentile": 119.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 67.05, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 67.05, "10th_percentile": 67.05, "90th_percentile": 67.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 100.43, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 100.43, "10th_percentile": 100.43, "90th_percentile": 100.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 111.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 111.75, "10th_percentile": 111.75, "90th_percentile": 111.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 130.38, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% 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 Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 80.98, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 80.98, "10th_percentile": 80.98, "90th_percentile": 80.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 97.07, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 97.07, "10th_percentile": 97.07, "90th_percentile": 97.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 121.73, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.73, "10th_percentile": 121.73, "90th_percentile": 121.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 37.85, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 37.85, "10th_percentile": 37.85, "90th_percentile": 37.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 51.85, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 51.85, "10th_percentile": 51.85, "90th_percentile": 51.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 103.26, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 149.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 149.0, "10th_percentile": 149.0, "90th_percentile": 149.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 149.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 149.0, "10th_percentile": 149.0, "90th_percentile": 149.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 28.31, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.31, "10th_percentile": 28.31, "90th_percentile": 28.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 28.31, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.31, "10th_percentile": 28.31, "90th_percentile": 28.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 28.31, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.31, "10th_percentile": 28.31, "90th_percentile": 28.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Cystoscopy and Treatment W/Dilation Male & Female", "code_information": [ { "code": "PX-36100619", "type": "CDM" }, { "code": "52281", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 2097.41, "maximum": 11039.0, "setting": "outpatient", "gross_charge": 11039.0, "discounted_cash": 7727.3, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6170.8, "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": 6170.8, "10th_percentile": 6170.8, "90th_percentile": 6170.8, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 5000.67, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5000.67, "10th_percentile": 5000.67, "90th_percentile": 5000.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 5331.84, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5331.84, "10th_percentile": 5331.84, "90th_percentile": 5331.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 9383.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 9383.15, "10th_percentile": 9383.15, "90th_percentile": 9383.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 8279.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 8279.25, "10th_percentile": 8279.25, "90th_percentile": 8279.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 5999.7, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 5999.7, "10th_percentile": 5999.7, "90th_percentile": 5999.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 7440.29, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 7440.29, "10th_percentile": 7440.29, "90th_percentile": 7440.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 9659.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 9659.13, "10th_percentile": 9659.13, "90th_percentile": 9659.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 8831.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 8831.2, "10th_percentile": 8831.2, "90th_percentile": 8831.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 4967.55, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 4967.55, "10th_percentile": 4967.55, "90th_percentile": 4967.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2097.41, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2097.41, "10th_percentile": 2097.41, "90th_percentile": 2097.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2097.41, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 2097.41, "10th_percentile": 2097.41, "90th_percentile": 2097.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 2803.91, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 2803.91, "10th_percentile": 2803.91, "90th_percentile": 2803.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 3841.57, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 3841.57, "10th_percentile": 3841.57, "90th_percentile": 3841.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 7650.03, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7650.03, "10th_percentile": 7650.03, "90th_percentile": 7650.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 7219.51, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7219.51, "10th_percentile": 7219.51, "90th_percentile": 7219.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 2097.41, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2097.41, "10th_percentile": 2097.41, "90th_percentile": 2097.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 11039.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11039.0, "10th_percentile": 11039.0, "90th_percentile": 11039.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 11039.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11039.0, "10th_percentile": 11039.0, "90th_percentile": 11039.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 7191.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 7191.91, "10th_percentile": 7191.91, "90th_percentile": 7191.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 7191.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 7191.91, "10th_percentile": 7191.91, "90th_percentile": 7191.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Debridement Subcutaneous Tissue 1st 20 Sq Cm/<", "code_information": [ { "code": "PX-36100016", "type": "CDM" }, { "code": "11042", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 1322.27, "maximum": 2634.0, "setting": "outpatient", "gross_charge": 2634.0, "discounted_cash": 1843.8, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2634.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2634.0, "10th_percentile": 2634.0, "90th_percentile": 2634.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1322.27, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1322.27, "10th_percentile": 1322.27, "90th_percentile": 1322.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1762.15, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1762.15, "10th_percentile": 1762.15, "90th_percentile": 1762.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Dialysis Circuit Vascular Embolization or Occlusion; S&I", "code_information": [ { "code": "PX-36100830", "type": "CDM" }, { "code": "36909", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 2199.26, "maximum": 4381.0, "setting": "outpatient", "gross_charge": 4381.0, "discounted_cash": 3066.7, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4381.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4381.0, "10th_percentile": 4381.0, "90th_percentile": 4381.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2199.26, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2199.26, "10th_percentile": 2199.26, "90th_percentile": 2199.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2930.89, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2930.89, "10th_percentile": 2930.89, "90th_percentile": 2930.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Dislocation Finger, Interphalangeal; W/Manipulation, W/O Anesthesia", "code_information": [ { "code": "PX-36100270", "type": "CDM" }, { "code": "26770", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 219.37, "maximum": 437.0, "setting": "outpatient", "gross_charge": 437.0, "discounted_cash": 305.9, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 437.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 437.0, "10th_percentile": 437.0, "90th_percentile": 437.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 219.37, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 219.37, "10th_percentile": 219.37, "90th_percentile": 219.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 292.35, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 292.35, "10th_percentile": 292.35, "90th_percentile": 292.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Doppler Color Flow Add-On", "code_information": [ { "code": "PX-48300001", "type": "CDM" }, { "code": "93325", "type": "CPT" }, { "code": "0483", "type": "RC" } ], "standard_charges": [ { "minimum": 234.46, "maximum": 1234.0, "setting": "outpatient", "gross_charge": 1234.0, "discounted_cash": 863.8, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 745.34, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 745.34, "10th_percentile": 745.34, "90th_percentile": 745.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 745.34, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 745.34, "10th_percentile": 745.34, "90th_percentile": 745.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 803.95, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 803.95, "10th_percentile": 803.95, "90th_percentile": 803.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 689.81, "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": 689.81, "10th_percentile": 689.81, "90th_percentile": 689.81, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 777.42, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 777.42, "10th_percentile": 777.42, "90th_percentile": 777.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1008.18, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1008.18, "10th_percentile": 1008.18, "90th_percentile": 1008.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 234.46, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 234.46, "10th_percentile": 234.46, "90th_percentile": 234.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 234.46, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 234.46, "10th_percentile": 234.46, "90th_percentile": 234.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 234.46, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 234.46, "10th_percentile": 234.46, "90th_percentile": 234.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1234.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1234.0, "10th_percentile": 1234.0, "90th_percentile": 1234.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1234.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1234.0, "10th_percentile": 1234.0, "90th_percentile": 1234.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 807.04, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 807.04, "10th_percentile": 807.04, "90th_percentile": 807.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 313.44, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 313.44, "10th_percentile": 313.44, "90th_percentile": 313.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 855.16, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 855.16, "10th_percentile": 855.16, "90th_percentile": 855.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 429.43, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 429.43, "10th_percentile": 429.43, "90th_percentile": 429.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1234.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1234.0, "10th_percentile": 1234.0, "90th_percentile": 1234.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1079.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1079.75, "10th_percentile": 1079.75, "90th_percentile": 1079.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 803.95, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 803.95, "10th_percentile": 803.95, "90th_percentile": 803.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 670.68, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 670.68, "10th_percentile": 670.68, "90th_percentile": 670.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 831.72, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 831.72, "10th_percentile": 831.72, "90th_percentile": 831.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 925.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 925.5, "10th_percentile": 925.5, "90th_percentile": 925.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1048.9, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1048.9, "10th_percentile": 1048.9, "90th_percentile": 1048.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 555.3, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 555.3, "10th_percentile": 555.3, "90th_percentile": 555.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 987.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 987.2, "10th_percentile": 987.2, "90th_percentile": 987.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1008.18, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1008.18, "10th_percentile": 1008.18, "90th_percentile": 1008.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 619.47, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 619.47, "10th_percentile": 619.47, "90th_percentile": 619.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 825.55, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.55, "10th_percentile": 825.55, "90th_percentile": 825.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 596.02, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 596.02, "10th_percentile": 596.02, "90th_percentile": 596.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 559.0, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 559.0, "10th_percentile": 559.0, "90th_percentile": 559.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Drain External Ear; Simple", "code_information": [ { "code": "PX-36100723", "type": "CDM" }, { "code": "69000", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 109.25, "maximum": 575.0, "setting": "outpatient", "gross_charge": 575.0, "discounted_cash": 402.5, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 321.43, "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": 321.43, "10th_percentile": 321.43, "90th_percentile": 321.43, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 260.48, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 260.48, "10th_percentile": 260.48, "90th_percentile": 260.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 277.73, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 277.73, "10th_percentile": 277.73, "90th_percentile": 277.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 488.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 488.75, "10th_percentile": 488.75, "90th_percentile": 488.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 431.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 431.25, "10th_percentile": 431.25, "90th_percentile": 431.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 312.51, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 312.51, "10th_percentile": 312.51, "90th_percentile": 312.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 387.55, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 387.55, "10th_percentile": 387.55, "90th_percentile": 387.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 503.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 503.13, "10th_percentile": 503.13, "90th_percentile": 503.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 460.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 460.0, "10th_percentile": 460.0, "90th_percentile": 460.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 258.75, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 258.75, "10th_percentile": 258.75, "90th_percentile": 258.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 109.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 109.25, "10th_percentile": 109.25, "90th_percentile": 109.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 109.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 109.25, "10th_percentile": 109.25, "90th_percentile": 109.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 146.05, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 146.05, "10th_percentile": 146.05, "90th_percentile": 146.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 200.1, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 200.1, "10th_percentile": 200.1, "90th_percentile": 200.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 398.48, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 398.48, "10th_percentile": 398.48, "90th_percentile": 398.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 376.05, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 376.05, "10th_percentile": 376.05, "90th_percentile": 376.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 109.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 109.25, "10th_percentile": 109.25, "90th_percentile": 109.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 575.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 575.0, "10th_percentile": 575.0, "90th_percentile": 575.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 575.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 575.0, "10th_percentile": 575.0, "90th_percentile": 575.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 374.61, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 374.61, "10th_percentile": 374.61, "90th_percentile": 374.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 374.61, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 374.61, "10th_percentile": 374.61, "90th_percentile": 374.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Drain Hand Tendon Sheath", "code_information": [ { "code": "PX-36000099", "type": "CDM" }, { "code": "26020", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 965.2, "maximum": 5080.0, "setting": "outpatient", "gross_charge": 5080.0, "discounted_cash": 3556.0, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3200.4, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3200.4, "10th_percentile": 3200.4, "90th_percentile": 3200.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4150.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4150.36, "10th_percentile": 4150.36, "90th_percentile": 4150.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3068.32, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3068.32, "10th_percentile": 3068.32, "90th_percentile": 3068.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3068.32, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3068.32, "10th_percentile": 3068.32, "90th_percentile": 3068.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2839.72, "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": 2839.72, "10th_percentile": 2839.72, "90th_percentile": 2839.72, "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4150.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4150.36, "10th_percentile": 4150.36, "90th_percentile": 4150.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2301.24, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2301.24, "10th_percentile": 2301.24, "90th_percentile": 2301.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2453.64, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2453.64, "10th_percentile": 2453.64, "90th_percentile": 2453.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 4318.0, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4318.0, "10th_percentile": 4318.0, "90th_percentile": 4318.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3810.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 3810.0, "10th_percentile": 3810.0, "90th_percentile": 3810.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2760.98, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2760.98, "10th_percentile": 2760.98, "90th_percentile": 2760.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3423.92, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3423.92, "10th_percentile": 3423.92, "90th_percentile": 3423.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4445.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4445.0, "10th_percentile": 4445.0, "90th_percentile": 4445.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4064.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 4064.0, "10th_percentile": 4064.0, "90th_percentile": 4064.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2286.0, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2286.0, "10th_percentile": 2286.0, "90th_percentile": 2286.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1290.32, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1290.32, "10th_percentile": 1290.32, "90th_percentile": 1290.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1767.84, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1767.84, "10th_percentile": 1767.84, "90th_percentile": 1767.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3520.44, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3520.44, "10th_percentile": 3520.44, "90th_percentile": 3520.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3322.32, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3322.32, "10th_percentile": 3322.32, "90th_percentile": 3322.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 965.2, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 965.2, "10th_percentile": 965.2, "90th_percentile": 965.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 965.2, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 965.2, "10th_percentile": 965.2, "90th_percentile": 965.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 965.2, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 965.2, "10th_percentile": 965.2, "90th_percentile": 965.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5080.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5080.0, "10th_percentile": 5080.0, "90th_percentile": 5080.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5080.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5080.0, "10th_percentile": 5080.0, "90th_percentile": 5080.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 3309.62, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3309.62, "10th_percentile": 3309.62, "90th_percentile": 3309.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3309.62, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3309.62, "10th_percentile": 3309.62, "90th_percentile": 3309.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Drain Spinal Cord Cyst", "code_information": [ { "code": "PX-36000292", "type": "CDM" }, { "code": "62268", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "minimum": 443.65, "maximum": 2335.0, "setting": "outpatient", "gross_charge": 2335.0, "discounted_cash": 1634.5, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1521.25, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1521.25, "10th_percentile": 1521.25, "90th_percentile": 1521.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1473.62, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP Surgery; 63.11% Billed", "median_amount": 1473.62, "10th_percentile": 1473.62, "90th_percentile": 1473.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP Surgery; 63.11% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1903.03, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP Surgery; 81.5% Billed", "median_amount": 1903.03, "10th_percentile": 1903.03, "90th_percentile": 1903.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP Surgery; 81.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1565.85, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP Surgery; 67.06% Billed", "median_amount": 1565.85, "10th_percentile": 1565.85, "90th_percentile": 1565.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP Surgery; 67.06% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1315.77, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP Surgery; 56.35% Billed", "median_amount": 1315.77, "10th_percentile": 1315.77, "90th_percentile": 1315.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP Surgery; 56.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1305.27, "standard_charge_percentage": 55.9, "standard_charge_algorithm": "OP Surgery. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1305.27, "10th_percentile": 1305.27, "90th_percentile": 1305.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 443.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 443.65, "10th_percentile": 443.65, "90th_percentile": 443.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2335.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2335.0, "10th_percentile": 2335.0, "90th_percentile": 2335.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2335.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2335.0, "10th_percentile": 2335.0, "90th_percentile": 2335.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1527.09, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1527.09, "10th_percentile": 1527.09, "90th_percentile": 1527.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1618.16, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1618.16, "10th_percentile": 1618.16, "90th_percentile": 1618.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 593.09, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 593.09, "10th_percentile": 593.09, "90th_percentile": 593.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 812.58, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 812.58, "10th_percentile": 812.58, "90th_percentile": 812.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2335.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2335.0, "10th_percentile": 2335.0, "90th_percentile": 2335.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2043.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2043.13, "10th_percentile": 2043.13, "90th_percentile": 2043.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1521.25, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1521.25, "10th_percentile": 1521.25, "90th_percentile": 1521.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1269.07, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1269.07, "10th_percentile": 1269.07, "90th_percentile": 1269.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1573.79, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1573.79, "10th_percentile": 1573.79, "90th_percentile": 1573.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1751.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1751.25, "10th_percentile": 1751.25, "90th_percentile": 1751.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1984.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1984.75, "10th_percentile": 1984.75, "90th_percentile": 1984.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1050.75, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1050.75, "10th_percentile": 1050.75, "90th_percentile": 1050.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 1562.12, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1562.12, "10th_percentile": 1562.12, "90th_percentile": 1562.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1172.17, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1172.17, "10th_percentile": 1172.17, "90th_percentile": 1172.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1127.81, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1127.81, "10th_percentile": 1127.81, "90th_percentile": 1127.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1057.76, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1057.76, "10th_percentile": 1057.76, "90th_percentile": 1057.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH MEDICARE", "standard_charge_dollar": 443.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 443.65, "10th_percentile": 443.65, "90th_percentile": 443.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 443.65, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 443.65, "10th_percentile": 443.65, "90th_percentile": 443.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1903.03, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP Surgery; 81.5% Billed", "median_amount": 1903.03, "10th_percentile": 1903.03, "90th_percentile": 1903.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP Surgery; 81.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1984.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 1984.75, "10th_percentile": 1984.75, "90th_percentile": 1984.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" } ] } ] }, { "description": "HB Drainage of Forearm Lesion", "code_information": [ { "code": "PX-36100236", "type": "CDM" }, { "code": "25028", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 2126.47, "maximum": 4236.0, "setting": "outpatient", "gross_charge": 4236.0, "discounted_cash": 2965.2, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4236.0, "10th_percentile": 4236.0, "90th_percentile": 4236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2126.47, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2126.47, "10th_percentile": 2126.47, "90th_percentile": 2126.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2833.88, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2833.88, "10th_percentile": 2833.88, "90th_percentile": 2833.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Ds Dna Antibody", "code_information": [ { "code": "PX-30209175", "type": "CDM" }, { "code": "86225", "type": "CPT" }, { "code": "0302", "type": "RC" } ], "standard_charges": [ { "minimum": 28.5, "maximum": 150.0, "setting": "outpatient", "gross_charge": 150.0, "discounted_cash": 105.0, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 150.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 150.0, "10th_percentile": 150.0, "90th_percentile": 150.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 150.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 150.0, "10th_percentile": 150.0, "90th_percentile": 150.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 122.55, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.55, "10th_percentile": 122.55, "90th_percentile": 122.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 131.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 131.25, "10th_percentile": 131.25, "90th_percentile": 131.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 127.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 127.5, "10th_percentile": 127.5, "90th_percentile": 127.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 97.73, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 97.73, "10th_percentile": 97.73, "90th_percentile": 97.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 150.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 150.0, "10th_percentile": 150.0, "90th_percentile": 150.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 112.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 112.5, "10th_percentile": 112.5, "90th_percentile": 112.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 101.1, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 101.1, "10th_percentile": 101.1, "90th_percentile": 101.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 120.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 120.0, "10th_percentile": 120.0, "90th_percentile": 120.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 81.53, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 81.53, "10th_percentile": 81.53, "90th_percentile": 81.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 67.5, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 67.5, "10th_percentile": 67.5, "90th_percentile": 67.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 103.95, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 103.95, "10th_percentile": 103.95, "90th_percentile": 103.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 52.2, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 52.2, "10th_percentile": 52.2, "90th_percentile": 52.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 38.1, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 38.1, "10th_percentile": 38.1, "90th_percentile": 38.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 122.55, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.55, "10th_percentile": 122.55, "90th_percentile": 122.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 94.5, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.5, "10th_percentile": 94.5, "90th_percentile": 94.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 83.85, "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": 83.85, "10th_percentile": 83.85, "90th_percentile": 83.85, "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": "VWH BCBS HMO", "standard_charge_dollar": 97.73, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 97.73, "10th_percentile": 97.73, "90th_percentile": 97.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 90.6, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.6, "10th_percentile": 90.6, "90th_percentile": 90.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 90.6, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.6, "10th_percentile": 90.6, "90th_percentile": 90.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 28.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.02, "10th_percentile": 28.02, "90th_percentile": 28.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 28.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.5, "10th_percentile": 28.5, "90th_percentile": 28.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 28.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 28.5, "10th_percentile": 28.5, "90th_percentile": 28.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Dstrj Neurolytic Agent Pudendal Nerve", "code_information": [ { "code": "PX-76100071", "type": "CDM" }, { "code": "64630", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 2048.16, "maximum": 4080.0, "setting": "outpatient", "gross_charge": 4080.0, "discounted_cash": 2856.0, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4080.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4080.0, "10th_percentile": 4080.0, "90th_percentile": 4080.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2048.16, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2048.16, "10th_percentile": 2048.16, "90th_percentile": 2048.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2729.52, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2729.52, "10th_percentile": 2729.52, "90th_percentile": 2729.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Ebv Panel, Early Antigen (Ea)", "code_information": [ { "code": "PX-30209185", "type": "CDM" }, { "code": "86663", "type": "CPT" }, { "code": "0302", "type": "RC" } ], "standard_charges": [ { "minimum": 16.72, "maximum": 88.0, "setting": "outpatient", "gross_charge": 88.0, "discounted_cash": 61.6, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 88.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 88.0, "10th_percentile": 88.0, "90th_percentile": 88.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 88.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 88.0, "10th_percentile": 88.0, "90th_percentile": 88.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 71.9, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.9, "10th_percentile": 71.9, "90th_percentile": 71.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 77.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 77.0, "10th_percentile": 77.0, "90th_percentile": 77.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 74.8, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 74.8, "10th_percentile": 74.8, "90th_percentile": 74.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 57.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 57.33, "10th_percentile": 57.33, "90th_percentile": 57.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 88.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 88.0, "10th_percentile": 88.0, "90th_percentile": 88.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 66.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 66.0, "10th_percentile": 66.0, "90th_percentile": 66.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 59.31, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 59.31, "10th_percentile": 59.31, "90th_percentile": 59.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 70.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 70.4, "10th_percentile": 70.4, "90th_percentile": 70.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 47.83, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 47.83, "10th_percentile": 47.83, "90th_percentile": 47.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 39.6, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 39.6, "10th_percentile": 39.6, "90th_percentile": 39.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 60.98, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.98, "10th_percentile": 60.98, "90th_percentile": 60.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 30.62, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 30.62, "10th_percentile": 30.62, "90th_percentile": 30.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 22.35, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 22.35, "10th_percentile": 22.35, "90th_percentile": 22.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 71.9, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.9, "10th_percentile": 71.9, "90th_percentile": 71.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 55.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.44, "10th_percentile": 55.44, "90th_percentile": 55.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 49.19, "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": 49.19, "10th_percentile": 49.19, "90th_percentile": 49.19, "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 57.33, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 57.33, "10th_percentile": 57.33, "90th_percentile": 57.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 53.15, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.15, "10th_percentile": 53.15, "90th_percentile": 53.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 53.15, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.15, "10th_percentile": 53.15, "90th_percentile": 53.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 16.72, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 16.72, "10th_percentile": 16.72, "90th_percentile": 16.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 16.72, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 16.72, "10th_percentile": 16.72, "90th_percentile": 16.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 16.72, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 16.72, "10th_percentile": 16.72, "90th_percentile": 16.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Echo Cong Heart-Complete", "code_information": [ { "code": "PX-48000033", "type": "CDM" }, { "code": "93303", "type": "CPT" }, { "code": "0480", "type": "RC" } ], "standard_charges": [ { "minimum": 670.89, "maximum": 3531.0, "setting": "outpatient", "gross_charge": 3531.0, "discounted_cash": 2471.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2132.72, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2132.72, "10th_percentile": 2132.72, "90th_percentile": 2132.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2132.72, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2132.72, "10th_percentile": 2132.72, "90th_percentile": 2132.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2300.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2300.45, "10th_percentile": 2300.45, "90th_percentile": 2300.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1973.83, "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": 1973.83, "10th_percentile": 1973.83, "90th_percentile": 1973.83, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2224.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2224.53, "10th_percentile": 2224.53, "90th_percentile": 2224.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2884.83, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2884.83, "10th_percentile": 2884.83, "90th_percentile": 2884.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 670.89, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 670.89, "10th_percentile": 670.89, "90th_percentile": 670.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 670.89, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 670.89, "10th_percentile": 670.89, "90th_percentile": 670.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 670.89, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 670.89, "10th_percentile": 670.89, "90th_percentile": 670.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3531.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3531.0, "10th_percentile": 3531.0, "90th_percentile": 3531.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3531.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3531.0, "10th_percentile": 3531.0, "90th_percentile": 3531.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3531.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3531.0, "10th_percentile": 3531.0, "90th_percentile": 3531.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 3089.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 3089.63, "10th_percentile": 3089.63, "90th_percentile": 3089.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2300.45, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2300.45, "10th_percentile": 2300.45, "90th_percentile": 2300.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1919.1, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1919.1, "10th_percentile": 1919.1, "90th_percentile": 1919.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2379.89, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2379.89, "10th_percentile": 2379.89, "90th_percentile": 2379.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2648.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2648.25, "10th_percentile": 2648.25, "90th_percentile": 2648.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 3001.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 3001.35, "10th_percentile": 3001.35, "90th_percentile": 3001.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1588.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1588.95, "10th_percentile": 1588.95, "90th_percentile": 1588.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2824.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2824.8, "10th_percentile": 2824.8, "90th_percentile": 2824.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2884.83, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2884.83, "10th_percentile": 2884.83, "90th_percentile": 2884.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1772.56, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1772.56, "10th_percentile": 1772.56, "90th_percentile": 1772.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2362.24, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2362.24, "10th_percentile": 2362.24, "90th_percentile": 2362.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1705.47, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1705.47, "10th_percentile": 1705.47, "90th_percentile": 1705.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1599.54, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1599.54, "10th_percentile": 1599.54, "90th_percentile": 1599.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Echo Fetal Heart Complete Pulsed and/or Continuous", "code_information": [ { "code": "PX-40200032", "type": "CDM" }, { "code": "76827", "type": "CPT" }, { "code": "0402", "type": "RC" } ], "standard_charges": [ { "minimum": 268.09, "maximum": 1411.0, "setting": "outpatient", "gross_charge": 1411.0, "discounted_cash": 987.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 852.24, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 852.24, "10th_percentile": 852.24, "90th_percentile": 852.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 852.24, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 852.24, "10th_percentile": 852.24, "90th_percentile": 852.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 919.27, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 919.27, "10th_percentile": 919.27, "90th_percentile": 919.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 788.75, "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": 788.75, "10th_percentile": 788.75, "90th_percentile": 788.75, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 888.93, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 888.93, "10th_percentile": 888.93, "90th_percentile": 888.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1152.79, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1152.79, "10th_percentile": 1152.79, "90th_percentile": 1152.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 268.09, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 268.09, "10th_percentile": 268.09, "90th_percentile": 268.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 268.09, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 268.09, "10th_percentile": 268.09, "90th_percentile": 268.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 268.09, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 268.09, "10th_percentile": 268.09, "90th_percentile": 268.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1411.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1411.0, "10th_percentile": 1411.0, "90th_percentile": 1411.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1411.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1411.0, "10th_percentile": 1411.0, "90th_percentile": 1411.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 922.79, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 922.79, "10th_percentile": 922.79, "90th_percentile": 922.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 358.39, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 358.39, "10th_percentile": 358.39, "90th_percentile": 358.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 977.82, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 977.82, "10th_percentile": 977.82, "90th_percentile": 977.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 491.03, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 491.03, "10th_percentile": 491.03, "90th_percentile": 491.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1411.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1411.0, "10th_percentile": 1411.0, "90th_percentile": 1411.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1234.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1234.63, "10th_percentile": 1234.63, "90th_percentile": 1234.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 919.27, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 919.27, "10th_percentile": 919.27, "90th_percentile": 919.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 766.88, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 766.88, "10th_percentile": 766.88, "90th_percentile": 766.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 951.01, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 951.01, "10th_percentile": 951.01, "90th_percentile": 951.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1058.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1058.25, "10th_percentile": 1058.25, "90th_percentile": 1058.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 1199.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1199.35, "10th_percentile": 1199.35, "90th_percentile": 1199.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 634.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 634.95, "10th_percentile": 634.95, "90th_percentile": 634.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1128.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1128.8, "10th_percentile": 1128.8, "90th_percentile": 1128.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1152.79, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1152.79, "10th_percentile": 1152.79, "90th_percentile": 1152.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Ecmo/Ecls Initiation Veno-Venous", "code_information": [ { "code": "PX-36100985", "type": "CDM" }, { "code": "33946", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 2095.85, "maximum": 4175.0, "setting": "outpatient", "gross_charge": 4175.0, "discounted_cash": 2922.5, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4175.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4175.0, "10th_percentile": 4175.0, "90th_percentile": 4175.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2095.85, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2095.85, "10th_percentile": 2095.85, "90th_percentile": 2095.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2793.08, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2793.08, "10th_percentile": 2793.08, "90th_percentile": 2793.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Ecmo/Ecls Repos Perph Cannula Prq 6 Yrs & Older", "code_information": [ { "code": "PX-36100990", "type": "CDM" }, { "code": "33958", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 598.89, "maximum": 1193.0, "setting": "outpatient", "gross_charge": 1193.0, "discounted_cash": 835.1, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1193.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1193.0, "10th_percentile": 1193.0, "90th_percentile": 1193.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 598.89, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 598.89, "10th_percentile": 598.89, "90th_percentile": 598.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 798.12, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 798.12, "10th_percentile": 798.12, "90th_percentile": 798.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Ecmo/Ecls Rmvl of Prph Cannula Prq 6 Yrs & Older", "code_information": [ { "code": "PX-36100991", "type": "CDM" }, { "code": "33966", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 283.29, "maximum": 1491.0, "setting": "outpatient", "gross_charge": 1491.0, "discounted_cash": 1043.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 833.47, "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": 833.47, "10th_percentile": 833.47, "90th_percentile": 833.47, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 675.42, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 675.42, "10th_percentile": 675.42, "90th_percentile": 675.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 720.15, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 720.15, "10th_percentile": 720.15, "90th_percentile": 720.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 1267.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1267.35, "10th_percentile": 1267.35, "90th_percentile": 1267.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1118.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1118.25, "10th_percentile": 1118.25, "90th_percentile": 1118.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 810.36, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 810.36, "10th_percentile": 810.36, "90th_percentile": 810.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1004.93, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1004.93, "10th_percentile": 1004.93, "90th_percentile": 1004.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1304.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1304.63, "10th_percentile": 1304.63, "90th_percentile": 1304.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1192.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1192.8, "10th_percentile": 1192.8, "90th_percentile": 1192.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 670.95, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 670.95, "10th_percentile": 670.95, "90th_percentile": 670.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 283.29, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 283.29, "10th_percentile": 283.29, "90th_percentile": 283.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 283.29, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 283.29, "10th_percentile": 283.29, "90th_percentile": 283.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 378.71, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 378.71, "10th_percentile": 378.71, "90th_percentile": 378.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 518.87, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 518.87, "10th_percentile": 518.87, "90th_percentile": 518.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1033.26, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1033.26, "10th_percentile": 1033.26, "90th_percentile": 1033.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 975.11, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 975.11, "10th_percentile": 975.11, "90th_percentile": 975.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 283.29, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 283.29, "10th_percentile": 283.29, "90th_percentile": 283.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1491.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1491.0, "10th_percentile": 1491.0, "90th_percentile": 1491.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1491.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1491.0, "10th_percentile": 1491.0, "90th_percentile": 1491.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 971.39, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 971.39, "10th_percentile": 971.39, "90th_percentile": 971.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 971.39, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 971.39, "10th_percentile": 971.39, "90th_percentile": 971.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Egd Flexible Transnasal W/Insj Intral Tube/Cath", "code_information": [ { "code": "PX-75000310", "type": "CDM" }, { "code": "0654T", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 382.33, "maximum": 5541.0, "setting": "outpatient", "gross_charge": 5541.0, "discounted_cash": 3878.7, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1052.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1052.79, "10th_percentile": 1052.79, "90th_percentile": 1052.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1052.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1052.79, "10th_percentile": 1052.79, "90th_percentile": 1052.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1052.79, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1052.79, "10th_percentile": 1052.79, "90th_percentile": 1052.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4527.0, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4527.0, "10th_percentile": 4527.0, "90th_percentile": 4527.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2510.07, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2510.07, "10th_percentile": 2510.07, "90th_percentile": 2510.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2676.3, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2676.3, "10th_percentile": 2676.3, "90th_percentile": 2676.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3609.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3609.96, "10th_percentile": 3609.96, "90th_percentile": 3609.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4155.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4155.75, "10th_percentile": 4155.75, "90th_percentile": 4155.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3734.63, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3734.63, "10th_percentile": 3734.63, "90th_percentile": 3734.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4848.38, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4848.38, "10th_percentile": 4848.38, "90th_percentile": 4848.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3011.53, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3011.53, "10th_percentile": 3011.53, "90th_percentile": 3011.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2493.45, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2493.45, "10th_percentile": 2493.45, "90th_percentile": 2493.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 4709.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4709.85, "10th_percentile": 4709.85, "90th_percentile": 4709.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4709.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 4709.85, "10th_percentile": 4709.85, "90th_percentile": 4709.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 382.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 382.33, "10th_percentile": 382.33, "90th_percentile": 382.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 382.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 382.33, "10th_percentile": 382.33, "90th_percentile": 382.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 382.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 382.33, "10th_percentile": 382.33, "90th_percentile": 382.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 382.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 382.33, "10th_percentile": 382.33, "90th_percentile": 382.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 382.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 382.33, "10th_percentile": 382.33, "90th_percentile": 382.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 382.33, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 382.33, "10th_percentile": 382.33, "90th_percentile": 382.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5541.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5541.0, "10th_percentile": 5541.0, "90th_percentile": 5541.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2781.58, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2781.58, "10th_percentile": 2781.58, "90th_percentile": 2781.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3706.93, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3706.93, "10th_percentile": 3706.93, "90th_percentile": 3706.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3839.91, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3839.91, "10th_percentile": 3839.91, "90th_percentile": 3839.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3623.81, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3623.81, "10th_percentile": 3623.81, "90th_percentile": 3623.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1928.27, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1928.27, "10th_percentile": 1928.27, "90th_percentile": 1928.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1407.41, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1407.41, "10th_percentile": 1407.41, "90th_percentile": 1407.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5541.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5541.0, "10th_percentile": 5541.0, "90th_percentile": 5541.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5541.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5541.0, "10th_percentile": 5541.0, "90th_percentile": 5541.0, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3346.76, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3346.76, "10th_percentile": 3346.76, "90th_percentile": 3346.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3346.76, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3346.76, "10th_percentile": 3346.76, "90th_percentile": 3346.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3097.42, "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": 3097.42, "10th_percentile": 3097.42, "90th_percentile": 3097.42, "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": "VWH BCBS HMO", "standard_charge_dollar": 3609.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3609.96, "10th_percentile": 3609.96, "90th_percentile": 3609.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4527.0, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4527.0, "10th_percentile": 4527.0, "90th_percentile": 4527.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3490.83, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3490.83, "10th_percentile": 3490.83, "90th_percentile": 3490.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Egd W/Transmural Drain Cyst", "code_information": [ { "code": "PX-75000017", "type": "CDM" }, { "code": "43240", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 1187.5, "maximum": 6250.0, "setting": "outpatient", "gross_charge": 6250.0, "discounted_cash": 4375.0, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1187.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1187.5, "10th_percentile": 1187.5, "90th_percentile": 1187.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1187.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1187.5, "10th_percentile": 1187.5, "90th_percentile": 1187.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1187.5, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1187.5, "10th_percentile": 1187.5, "90th_percentile": 1187.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 5106.25, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5106.25, "10th_percentile": 5106.25, "90th_percentile": 5106.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2831.25, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2831.25, "10th_percentile": 2831.25, "90th_percentile": 2831.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 3018.75, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3018.75, "10th_percentile": 3018.75, "90th_percentile": 3018.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 4071.88, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4071.88, "10th_percentile": 4071.88, "90th_percentile": 4071.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4687.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4687.5, "10th_percentile": 4687.5, "90th_percentile": 4687.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 4212.5, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 4212.5, "10th_percentile": 4212.5, "90th_percentile": 4212.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 5468.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 5468.75, "10th_percentile": 5468.75, "90th_percentile": 5468.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3396.88, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3396.88, "10th_percentile": 3396.88, "90th_percentile": 3396.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2812.5, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2812.5, "10th_percentile": 2812.5, "90th_percentile": 2812.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 5312.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 5312.5, "10th_percentile": 5312.5, "90th_percentile": 5312.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 5312.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 5312.5, "10th_percentile": 5312.5, "90th_percentile": 5312.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6250.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6250.0, "10th_percentile": 6250.0, "90th_percentile": 6250.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 3137.5, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3137.5, "10th_percentile": 3137.5, "90th_percentile": 3137.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 4181.25, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4181.25, "10th_percentile": 4181.25, "90th_percentile": 4181.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 4331.25, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4331.25, "10th_percentile": 4331.25, "90th_percentile": 4331.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 4087.5, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4087.5, "10th_percentile": 4087.5, "90th_percentile": 4087.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2175.0, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2175.0, "10th_percentile": 2175.0, "90th_percentile": 2175.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1587.5, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1587.5, "10th_percentile": 1587.5, "90th_percentile": 1587.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6250.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6250.0, "10th_percentile": 6250.0, "90th_percentile": 6250.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6250.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6250.0, "10th_percentile": 6250.0, "90th_percentile": 6250.0, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3775.0, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3775.0, "10th_percentile": 3775.0, "90th_percentile": 3775.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3775.0, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3775.0, "10th_percentile": 3775.0, "90th_percentile": 3775.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3493.75, "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": 3493.75, "10th_percentile": 3493.75, "90th_percentile": 3493.75, "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": "VWH BCBS HMO", "standard_charge_dollar": 4071.88, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4071.88, "10th_percentile": 4071.88, "90th_percentile": 4071.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 5106.25, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5106.25, "10th_percentile": 5106.25, "90th_percentile": 5106.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3937.5, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3937.5, "10th_percentile": 3937.5, "90th_percentile": 3937.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Elect Anlys Implt Ithcl/Edrl Pmp W/Reprg&Refill", "code_information": [ { "code": "CASE-62369", "type": "LOCAL" }, { "code": "62369", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 20.72, "maximum": 2320.8, "setting": "outpatient", "gross_charge": 10898.74, "discounted_cash": 7629.12, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 3537.14, "10th_percentile": 3537.14, "90th_percentile": 3537.14, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 5046.58, "10th_percentile": 5046.58, "90th_percentile": 5046.58, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_percentage": 34.8, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 3792.76, "10th_percentile": 3792.76, "90th_percentile": 3792.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_percentage": 25.4, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2768.28, "10th_percentile": 2768.28, "90th_percentile": 2768.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2070.76, "10th_percentile": 2070.76, "90th_percentile": 2070.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 7100.53, "10th_percentile": 7100.53, "90th_percentile": 7100.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 81.7, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 8904.27, "10th_percentile": 8904.27, "90th_percentile": 8904.27, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2070.76, "10th_percentile": 2070.76, "90th_percentile": 2070.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 60.4, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 6582.85, "10th_percentile": 6582.85, "90th_percentile": 6582.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 6866.21, "10th_percentile": 6866.21, "90th_percentile": 6866.21, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 60.4, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 6582.85, "10th_percentile": 6582.85, "90th_percentile": 6582.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 7100.53, "10th_percentile": 7100.53, "90th_percentile": 7100.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 55.9, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 6092.4, "10th_percentile": 6092.4, "90th_percentile": 6092.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 81.7, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 8904.27, "10th_percentile": 8904.27, "90th_percentile": 8904.27, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 7345.76, "10th_percentile": 7345.76, "90th_percentile": 7345.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2722.37, "10th_percentile": 2722.37, "90th_percentile": 2722.37, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2768.24, "10th_percentile": 2768.24, "90th_percentile": 2768.24, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 10898.75, "10th_percentile": 10898.75, "90th_percentile": 10898.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 2070.76, "10th_percentile": 2070.76, "90th_percentile": 2070.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 9263.94, "10th_percentile": 9263.94, "90th_percentile": 9263.94, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_percentage": 45.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 4904.44, "10th_percentile": 4904.44, "90th_percentile": 4904.44, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 8174.06, "10th_percentile": 8174.06, "90th_percentile": 8174.06, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_percentage": 87.5, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 9536.42, "10th_percentile": 9536.42, "90th_percentile": 9536.42, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 10898.75, "10th_percentile": 10898.75, "90th_percentile": 10898.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 8719.0, "10th_percentile": 8719.0, "90th_percentile": 8719.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 5923.47, "10th_percentile": 5923.47, "90th_percentile": 5923.47, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs can be included in reimbursement.", "median_amount": 10898.75, "10th_percentile": 10898.75, "90th_percentile": 10898.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2320.8, "standard_charge_algorithm": "Re-evaluated: HLB.877385828; Using new claim; Scope: All Financial Classes; Cases: 6; High Cost Drugs; FSC: NM HB XR UHC DRUG FSC 38910, Value: 2,320.80, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2321.3, "10th_percentile": 2321.3, "90th_percentile": 2321.3, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2320.8, "standard_charge_algorithm": "Re-evaluated: HLB.877385828; Using new claim; Scope: All Financial Classes; Cases: 6; High Cost Drugs; FSC: NM HB XR UHC DRUG FSC 38910, Value: 2,320.80, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2321.3, "10th_percentile": 2321.3, "90th_percentile": 2321.3, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.72, "standard_charge_algorithm": "Re-evaluated: HLB.877385828; Using new claim; Scope: All Financial Classes; Cases: 6; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 20.72, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 667.24, "10th_percentile": 667.24, "90th_percentile": 667.24, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.72, "standard_charge_algorithm": "Re-evaluated: HLB.877385828; Using new claim; Scope: All Financial Classes; Cases: 6; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 20.72, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 667.24, "10th_percentile": 667.24, "90th_percentile": 667.24, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.72, "standard_charge_algorithm": "Re-evaluated: HLB.877385828; Using new claim; Scope: All Financial Classes; Cases: 6; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 20.72, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 667.24, "10th_percentile": 667.24, "90th_percentile": 667.24, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.72, "standard_charge_algorithm": "Re-evaluated: HLB.877385828; Using new claim; Scope: All Financial Classes; Cases: 6; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 20.72, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 667.24, "10th_percentile": 667.24, "90th_percentile": 667.24, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.72, "standard_charge_algorithm": "Re-evaluated: HLB.877385828; Using new claim; Scope: All Financial Classes; Cases: 6; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 20.72, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 667.24, "10th_percentile": 667.24, "90th_percentile": 667.24, "count": "1 through 10", "methodology": "fee schedule" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 20.72, "standard_charge_algorithm": "Re-evaluated: HLB.877385828; Using new claim; Scope: All Financial Classes; Cases: 6; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 20.72, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 667.24, "10th_percentile": 667.24, "90th_percentile": 667.24, "count": "1 through 10", "methodology": "fee schedule" } ] } ] }, { "description": "HB Enteroscopy W/ Banding, Ablation, Snare - Unlisted", "code_information": [ { "code": "PX-75000427", "type": "CDM" }, { "code": "44799", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 950.61, "maximum": 13777.0, "setting": "outpatient", "gross_charge": 13777.0, "discounted_cash": 9643.9, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 8975.72, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 8975.72, "10th_percentile": 8975.72, "90th_percentile": 8975.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 11255.81, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11255.81, "10th_percentile": 11255.81, "90th_percentile": 11255.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 6240.98, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6240.98, "10th_percentile": 6240.98, "90th_percentile": 6240.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 9285.7, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 9285.7, "10th_percentile": 9285.7, "90th_percentile": 9285.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 6654.29, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6654.29, "10th_percentile": 6654.29, "90th_percentile": 6654.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH THE ALLIANCE", "standard_charge_dollar": 7487.8, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 7487.8, "10th_percentile": 7487.8, "90th_percentile": 7487.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 12054.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 12054.88, "10th_percentile": 12054.88, "90th_percentile": 12054.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 10332.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 10332.75, "10th_percentile": 10332.75, "90th_percentile": 10332.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 6199.65, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 6199.65, "10th_percentile": 6199.65, "90th_percentile": 6199.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 11710.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 11710.45, "10th_percentile": 11710.45, "90th_percentile": 11710.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 11710.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 11710.45, "10th_percentile": 11710.45, "90th_percentile": 11710.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 13777.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 13777.0, "10th_percentile": 13777.0, "90th_percentile": 13777.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 9216.81, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9216.81, "10th_percentile": 9216.81, "90th_percentile": 9216.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 6916.05, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6916.05, "10th_percentile": 6916.05, "90th_percentile": 6916.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 9010.16, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9010.16, "10th_percentile": 9010.16, "90th_percentile": 9010.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 9547.46, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9547.46, "10th_percentile": 9547.46, "90th_percentile": 9547.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 3499.36, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 3499.36, "10th_percentile": 3499.36, "90th_percentile": 3499.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 4794.4, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 4794.4, "10th_percentile": 4794.4, "90th_percentile": 4794.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13777.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13777.0, "10th_percentile": 13777.0, "90th_percentile": 13777.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13777.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13777.0, "10th_percentile": 13777.0, "90th_percentile": 13777.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 8975.72, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 8975.72, "10th_percentile": 8975.72, "90th_percentile": 8975.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7701.34, "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": 7701.34, "10th_percentile": 7701.34, "90th_percentile": 7701.34, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8679.51, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8679.51, "10th_percentile": 8679.51, "90th_percentile": 8679.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 11255.81, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11255.81, "10th_percentile": 11255.81, "90th_percentile": 11255.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8321.31, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8321.31, "10th_percentile": 8321.31, "90th_percentile": 8321.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8321.31, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8321.31, "10th_percentile": 8321.31, "90th_percentile": 8321.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 2617.63, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2617.63, "10th_percentile": 2617.63, "90th_percentile": 2617.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2617.63, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2617.63, "10th_percentile": 2617.63, "90th_percentile": 2617.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2617.63, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2617.63, "10th_percentile": 2617.63, "90th_percentile": 2617.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 950.61, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 950.61, "10th_percentile": 950.61, "90th_percentile": 950.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 950.61, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 950.61, "10th_percentile": 950.61, "90th_percentile": 950.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 950.61, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 950.61, "10th_percentile": 950.61, "90th_percentile": 950.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 950.61, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 950.61, "10th_percentile": 950.61, "90th_percentile": 950.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 950.61, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 950.61, "10th_percentile": 950.61, "90th_percentile": 950.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 950.61, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 950.61, "10th_percentile": 950.61, "90th_percentile": 950.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Ercp Roux-en-Y Anatomy W/3 Stents Placed", "code_information": [ { "code": "PX-75000266", "type": "CDM" }, { "code": "47999", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 1851.82, "maximum": 26838.0, "setting": "outpatient", "gross_charge": 26838.0, "discounted_cash": 18786.6, "payers_information": [ { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 14586.45, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 14586.45, "10th_percentile": 14586.45, "90th_percentile": 14586.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 23483.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 23483.25, "10th_percentile": 23483.25, "90th_percentile": 23483.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 20128.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 20128.5, "10th_percentile": 20128.5, "90th_percentile": 20128.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 12077.1, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 12077.1, "10th_percentile": 12077.1, "90th_percentile": 12077.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 12962.75, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12962.75, "10th_percentile": 12962.75, "90th_percentile": 12962.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 12157.61, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12157.61, "10th_percentile": 12157.61, "90th_percentile": 12157.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 18088.81, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 18088.81, "10th_percentile": 18088.81, "90th_percentile": 18088.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 21926.65, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21926.65, "10th_percentile": 21926.65, "90th_percentile": 21926.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 17484.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 17484.96, "10th_percentile": 17484.96, "90th_percentile": 17484.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 22812.3, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 22812.3, "10th_percentile": 22812.3, "90th_percentile": 22812.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 22812.3, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 22812.3, "10th_percentile": 22812.3, "90th_percentile": 22812.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 26838.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 26838.0, "10th_percentile": 26838.0, "90th_percentile": 26838.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 17954.62, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17954.62, "10th_percentile": 17954.62, "90th_percentile": 17954.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 13472.68, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13472.68, "10th_percentile": 13472.68, "90th_percentile": 13472.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 6816.85, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 6816.85, "10th_percentile": 6816.85, "90th_percentile": 6816.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 9339.62, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 9339.62, "10th_percentile": 9339.62, "90th_percentile": 9339.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 18598.73, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18598.73, "10th_percentile": 18598.73, "90th_percentile": 18598.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 17552.05, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17552.05, "10th_percentile": 17552.05, "90th_percentile": 17552.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 26838.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 26838.0, "10th_percentile": 26838.0, "90th_percentile": 26838.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 26838.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 26838.0, "10th_percentile": 26838.0, "90th_percentile": 26838.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 17484.96, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 17484.96, "10th_percentile": 17484.96, "90th_percentile": 17484.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 15002.44, "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": 15002.44, "10th_percentile": 15002.44, "90th_percentile": 15002.44, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 16907.94, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16907.94, "10th_percentile": 16907.94, "90th_percentile": 16907.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 21926.65, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21926.65, "10th_percentile": 21926.65, "90th_percentile": 21926.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 16210.15, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16210.15, "10th_percentile": 16210.15, "90th_percentile": 16210.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 16210.15, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16210.15, "10th_percentile": 16210.15, "90th_percentile": 16210.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 5099.22, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 5099.22, "10th_percentile": 5099.22, "90th_percentile": 5099.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 5099.22, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 5099.22, "10th_percentile": 5099.22, "90th_percentile": 5099.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 5099.22, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 5099.22, "10th_percentile": 5099.22, "90th_percentile": 5099.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1851.82, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1851.82, "10th_percentile": 1851.82, "90th_percentile": 1851.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1851.82, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1851.82, "10th_percentile": 1851.82, "90th_percentile": 1851.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1851.82, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1851.82, "10th_percentile": 1851.82, "90th_percentile": 1851.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1851.82, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1851.82, "10th_percentile": 1851.82, "90th_percentile": 1851.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1851.82, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1851.82, "10th_percentile": 1851.82, "90th_percentile": 1851.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1851.82, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1851.82, "10th_percentile": 1851.82, "90th_percentile": 1851.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Ercp W/Control of Bleed, Biliary Tract - Unlisted", "code_information": [ { "code": "PX-75000285", "type": "CDM" }, { "code": "47999", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 356.73, "maximum": 5170.0, "setting": "outpatient", "gross_charge": 5170.0, "discounted_cash": 3619.0, "payers_information": [ { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2809.9, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2809.9, "10th_percentile": 2809.9, "90th_percentile": 2809.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4523.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4523.75, "10th_percentile": 4523.75, "90th_percentile": 4523.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3877.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 3877.5, "10th_percentile": 3877.5, "90th_percentile": 3877.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2326.5, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2326.5, "10th_percentile": 2326.5, "90th_percentile": 2326.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2497.11, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2497.11, "10th_percentile": 2497.11, "90th_percentile": 2497.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2342.01, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2342.01, "10th_percentile": 2342.01, "90th_percentile": 2342.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3484.58, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3484.58, "10th_percentile": 3484.58, "90th_percentile": 3484.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4223.89, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4223.89, "10th_percentile": 4223.89, "90th_percentile": 4223.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3368.26, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3368.26, "10th_percentile": 3368.26, "90th_percentile": 3368.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4394.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 4394.5, "10th_percentile": 4394.5, "90th_percentile": 4394.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 4394.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4394.5, "10th_percentile": 4394.5, "90th_percentile": 4394.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5170.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5170.0, "10th_percentile": 5170.0, "90th_percentile": 5170.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3458.73, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3458.73, "10th_percentile": 3458.73, "90th_percentile": 3458.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2595.34, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2595.34, "10th_percentile": 2595.34, "90th_percentile": 2595.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1313.18, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1313.18, "10th_percentile": 1313.18, "90th_percentile": 1313.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1799.16, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1799.16, "10th_percentile": 1799.16, "90th_percentile": 1799.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3582.81, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3582.81, "10th_percentile": 3582.81, "90th_percentile": 3582.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3381.18, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3381.18, "10th_percentile": 3381.18, "90th_percentile": 3381.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5170.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5170.0, "10th_percentile": 5170.0, "90th_percentile": 5170.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5170.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5170.0, "10th_percentile": 5170.0, "90th_percentile": 5170.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 3368.26, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3368.26, "10th_percentile": 3368.26, "90th_percentile": 3368.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2890.03, "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": 2890.03, "10th_percentile": 2890.03, "90th_percentile": 2890.03, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3257.1, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3257.1, "10th_percentile": 3257.1, "90th_percentile": 3257.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4223.89, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4223.89, "10th_percentile": 4223.89, "90th_percentile": 4223.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3122.68, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3122.68, "10th_percentile": 3122.68, "90th_percentile": 3122.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3122.68, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3122.68, "10th_percentile": 3122.68, "90th_percentile": 3122.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 982.3, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 982.3, "10th_percentile": 982.3, "90th_percentile": 982.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 982.3, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 982.3, "10th_percentile": 982.3, "90th_percentile": 982.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 982.3, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 982.3, "10th_percentile": 982.3, "90th_percentile": 982.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.73, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.73, "10th_percentile": 356.73, "90th_percentile": 356.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.73, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.73, "10th_percentile": 356.73, "90th_percentile": 356.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.73, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.73, "10th_percentile": 356.73, "90th_percentile": 356.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.73, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.73, "10th_percentile": 356.73, "90th_percentile": 356.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.73, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.73, "10th_percentile": 356.73, "90th_percentile": 356.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.73, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.73, "10th_percentile": 356.73, "90th_percentile": 356.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Ercp via Altered Anatomy, Biliary Foreign Body and Calculi/Debris Removal", "code_information": [ { "code": "PX-75009023", "type": "CDM" }, { "code": "47999", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 1065.84, "maximum": 15447.0, "setting": "outpatient", "gross_charge": 15447.0, "discounted_cash": 10812.9, "payers_information": [ { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 8395.44, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 8395.44, "10th_percentile": 8395.44, "90th_percentile": 8395.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 13516.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 13516.13, "10th_percentile": 13516.13, "90th_percentile": 13516.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 11585.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 11585.25, "10th_percentile": 11585.25, "90th_percentile": 11585.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 6951.15, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 6951.15, "10th_percentile": 6951.15, "90th_percentile": 6951.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 7460.9, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7460.9, "10th_percentile": 7460.9, "90th_percentile": 7460.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 6997.49, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6997.49, "10th_percentile": 6997.49, "90th_percentile": 6997.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 10411.28, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 10411.28, "10th_percentile": 10411.28, "90th_percentile": 10411.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 12620.2, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12620.2, "10th_percentile": 12620.2, "90th_percentile": 12620.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 10063.72, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10063.72, "10th_percentile": 10063.72, "90th_percentile": 10063.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 13129.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 13129.95, "10th_percentile": 13129.95, "90th_percentile": 13129.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 13129.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 13129.95, "10th_percentile": 13129.95, "90th_percentile": 13129.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 15447.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 15447.0, "10th_percentile": 15447.0, "90th_percentile": 15447.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 10334.04, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10334.04, "10th_percentile": 10334.04, "90th_percentile": 10334.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 7754.39, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7754.39, "10th_percentile": 7754.39, "90th_percentile": 7754.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 3923.54, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 3923.54, "10th_percentile": 3923.54, "90th_percentile": 3923.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 5375.56, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 5375.56, "10th_percentile": 5375.56, "90th_percentile": 5375.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 10704.77, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10704.77, "10th_percentile": 10704.77, "90th_percentile": 10704.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 10102.34, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10102.34, "10th_percentile": 10102.34, "90th_percentile": 10102.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 15447.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 15447.0, "10th_percentile": 15447.0, "90th_percentile": 15447.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 15447.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 15447.0, "10th_percentile": 15447.0, "90th_percentile": 15447.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 10063.72, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10063.72, "10th_percentile": 10063.72, "90th_percentile": 10063.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8634.87, "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": 8634.87, "10th_percentile": 8634.87, "90th_percentile": 8634.87, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9731.61, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9731.61, "10th_percentile": 9731.61, "90th_percentile": 9731.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 12620.2, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12620.2, "10th_percentile": 12620.2, "90th_percentile": 12620.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9329.99, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9329.99, "10th_percentile": 9329.99, "90th_percentile": 9329.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9329.99, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9329.99, "10th_percentile": 9329.99, "90th_percentile": 9329.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 2934.93, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2934.93, "10th_percentile": 2934.93, "90th_percentile": 2934.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2934.93, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2934.93, "10th_percentile": 2934.93, "90th_percentile": 2934.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 2934.93, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 2934.93, "10th_percentile": 2934.93, "90th_percentile": 2934.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1065.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1065.84, "10th_percentile": 1065.84, "90th_percentile": 1065.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1065.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1065.84, "10th_percentile": 1065.84, "90th_percentile": 1065.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1065.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1065.84, "10th_percentile": 1065.84, "90th_percentile": 1065.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1065.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1065.84, "10th_percentile": 1065.84, "90th_percentile": 1065.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1065.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1065.84, "10th_percentile": 1065.84, "90th_percentile": 1065.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1065.84, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1065.84, "10th_percentile": 1065.84, "90th_percentile": 1065.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Ercp via Altered Anatomy, Biliary W Stent Exchange - Unlisted", "code_information": [ { "code": "PX-75000396", "type": "CDM" }, { "code": "47999", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 580.64, "maximum": 8415.0, "setting": "outpatient", "gross_charge": 8415.0, "discounted_cash": 5890.5, "payers_information": [ { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 4573.55, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 4573.55, "10th_percentile": 4573.55, "90th_percentile": 4573.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 7363.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 7363.13, "10th_percentile": 7363.13, "90th_percentile": 7363.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 6311.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 6311.25, "10th_percentile": 6311.25, "90th_percentile": 6311.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 3786.75, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 3786.75, "10th_percentile": 3786.75, "90th_percentile": 3786.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 4064.45, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4064.45, "10th_percentile": 4064.45, "90th_percentile": 4064.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 3812.0, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3812.0, "10th_percentile": 3812.0, "90th_percentile": 3812.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 5671.71, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 5671.71, "10th_percentile": 5671.71, "90th_percentile": 5671.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 6875.06, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6875.06, "10th_percentile": 6875.06, "90th_percentile": 6875.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 5482.37, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 5482.37, "10th_percentile": 5482.37, "90th_percentile": 5482.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 7152.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 7152.75, "10th_percentile": 7152.75, "90th_percentile": 7152.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 7152.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 7152.75, "10th_percentile": 7152.75, "90th_percentile": 7152.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8415.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8415.0, "10th_percentile": 8415.0, "90th_percentile": 8415.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 5629.64, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5629.64, "10th_percentile": 5629.64, "90th_percentile": 5629.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 4224.33, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4224.33, "10th_percentile": 4224.33, "90th_percentile": 4224.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 2137.41, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 2137.41, "10th_percentile": 2137.41, "90th_percentile": 2137.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2928.42, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2928.42, "10th_percentile": 2928.42, "90th_percentile": 2928.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 5831.6, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5831.6, "10th_percentile": 5831.6, "90th_percentile": 5831.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 5503.41, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5503.41, "10th_percentile": 5503.41, "90th_percentile": 5503.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8415.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8415.0, "10th_percentile": 8415.0, "90th_percentile": 8415.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8415.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8415.0, "10th_percentile": 8415.0, "90th_percentile": 8415.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 5482.37, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 5482.37, "10th_percentile": 5482.37, "90th_percentile": 5482.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4703.99, "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": 4703.99, "10th_percentile": 4703.99, "90th_percentile": 4703.99, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5301.45, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5301.45, "10th_percentile": 5301.45, "90th_percentile": 5301.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 6875.06, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6875.06, "10th_percentile": 6875.06, "90th_percentile": 6875.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5082.66, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5082.66, "10th_percentile": 5082.66, "90th_percentile": 5082.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5082.66, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5082.66, "10th_percentile": 5082.66, "90th_percentile": 5082.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1598.85, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1598.85, "10th_percentile": 1598.85, "90th_percentile": 1598.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1598.85, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1598.85, "10th_percentile": 1598.85, "90th_percentile": 1598.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1598.85, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1598.85, "10th_percentile": 1598.85, "90th_percentile": 1598.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 580.64, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 580.64, "10th_percentile": 580.64, "90th_percentile": 580.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 580.64, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 580.64, "10th_percentile": 580.64, "90th_percentile": 580.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 580.64, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 580.64, "10th_percentile": 580.64, "90th_percentile": 580.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 580.64, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 580.64, "10th_percentile": 580.64, "90th_percentile": 580.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 580.64, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 580.64, "10th_percentile": 580.64, "90th_percentile": 580.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 580.64, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 580.64, "10th_percentile": 580.64, "90th_percentile": 580.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Ercp, via Altered Anatomy, Biliary Foreign Body and Calculi/Debris Removal, Spyglass - Unlisted", "code_information": [ { "code": "PX-75000425", "type": "CDM" }, { "code": "47999", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 1112.76, "maximum": 16127.0, "setting": "outpatient", "gross_charge": 16127.0, "discounted_cash": 11288.9, "payers_information": [ { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 8765.02, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 8765.02, "10th_percentile": 8765.02, "90th_percentile": 8765.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 14111.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 14111.13, "10th_percentile": 14111.13, "90th_percentile": 14111.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 12095.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 12095.25, "10th_percentile": 12095.25, "90th_percentile": 12095.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 7257.15, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 7257.15, "10th_percentile": 7257.15, "90th_percentile": 7257.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 7789.34, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7789.34, "10th_percentile": 7789.34, "90th_percentile": 7789.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 7305.53, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7305.53, "10th_percentile": 7305.53, "90th_percentile": 7305.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 10869.6, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 10869.6, "10th_percentile": 10869.6, "90th_percentile": 10869.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 13175.76, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13175.76, "10th_percentile": 13175.76, "90th_percentile": 13175.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 10506.74, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10506.74, "10th_percentile": 10506.74, "90th_percentile": 10506.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 13707.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 13707.95, "10th_percentile": 13707.95, "90th_percentile": 13707.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 13707.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 13707.95, "10th_percentile": 13707.95, "90th_percentile": 13707.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 16127.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 16127.0, "10th_percentile": 16127.0, "90th_percentile": 16127.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 10788.96, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10788.96, "10th_percentile": 10788.96, "90th_percentile": 10788.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 8095.75, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8095.75, "10th_percentile": 8095.75, "90th_percentile": 8095.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 4096.26, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 4096.26, "10th_percentile": 4096.26, "90th_percentile": 4096.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 5612.2, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 5612.2, "10th_percentile": 5612.2, "90th_percentile": 5612.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 11176.01, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11176.01, "10th_percentile": 11176.01, "90th_percentile": 11176.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 10547.06, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10547.06, "10th_percentile": 10547.06, "90th_percentile": 10547.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16127.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16127.0, "10th_percentile": 16127.0, "90th_percentile": 16127.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16127.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16127.0, "10th_percentile": 16127.0, "90th_percentile": 16127.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 10506.74, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10506.74, "10th_percentile": 10506.74, "90th_percentile": 10506.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9014.99, "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": 9014.99, "10th_percentile": 9014.99, "90th_percentile": 9014.99, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10160.01, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10160.01, "10th_percentile": 10160.01, "90th_percentile": 10160.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 13175.76, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13175.76, "10th_percentile": 13175.76, "90th_percentile": 13175.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9740.71, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9740.71, "10th_percentile": 9740.71, "90th_percentile": 9740.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9740.71, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9740.71, "10th_percentile": 9740.71, "90th_percentile": 9740.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 3064.13, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3064.13, "10th_percentile": 3064.13, "90th_percentile": 3064.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3064.13, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3064.13, "10th_percentile": 3064.13, "90th_percentile": 3064.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3064.13, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3064.13, "10th_percentile": 3064.13, "90th_percentile": 3064.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1112.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1112.76, "10th_percentile": 1112.76, "90th_percentile": 1112.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1112.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1112.76, "10th_percentile": 1112.76, "90th_percentile": 1112.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1112.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1112.76, "10th_percentile": 1112.76, "90th_percentile": 1112.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1112.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1112.76, "10th_percentile": 1112.76, "90th_percentile": 1112.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1112.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1112.76, "10th_percentile": 1112.76, "90th_percentile": 1112.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1112.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1112.76, "10th_percentile": 1112.76, "90th_percentile": 1112.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Ercp, via Altered Anatomy, Biliary W/Calculi/Debris Removal, Stent Exchange X2 - Unlisted", "code_information": [ { "code": "PX-75009039", "type": "CDM" }, { "code": "47999", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 1159.13, "maximum": 16799.0, "setting": "outpatient", "gross_charge": 16799.0, "discounted_cash": 11759.3, "payers_information": [ { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 9130.26, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 9130.26, "10th_percentile": 9130.26, "90th_percentile": 9130.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 14699.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 14699.13, "10th_percentile": 14699.13, "90th_percentile": 14699.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 12599.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 12599.25, "10th_percentile": 12599.25, "90th_percentile": 12599.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 7559.55, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 7559.55, "10th_percentile": 7559.55, "90th_percentile": 7559.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 8113.92, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8113.92, "10th_percentile": 8113.92, "90th_percentile": 8113.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 7609.95, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7609.95, "10th_percentile": 7609.95, "90th_percentile": 7609.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 11322.53, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 11322.53, "10th_percentile": 11322.53, "90th_percentile": 11322.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 13724.78, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13724.78, "10th_percentile": 13724.78, "90th_percentile": 13724.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 10944.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10944.55, "10th_percentile": 10944.55, "90th_percentile": 10944.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 14279.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 14279.15, "10th_percentile": 14279.15, "90th_percentile": 14279.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 14279.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 14279.15, "10th_percentile": 14279.15, "90th_percentile": 14279.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 16799.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 16799.0, "10th_percentile": 16799.0, "90th_percentile": 16799.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 11238.53, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11238.53, "10th_percentile": 11238.53, "90th_percentile": 11238.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 8433.1, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8433.1, "10th_percentile": 8433.1, "90th_percentile": 8433.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 4266.95, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 4266.95, "10th_percentile": 4266.95, "90th_percentile": 4266.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 5846.05, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 5846.05, "10th_percentile": 5846.05, "90th_percentile": 5846.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 11641.71, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11641.71, "10th_percentile": 11641.71, "90th_percentile": 11641.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 10986.55, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10986.55, "10th_percentile": 10986.55, "90th_percentile": 10986.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16799.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16799.0, "10th_percentile": 16799.0, "90th_percentile": 16799.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16799.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16799.0, "10th_percentile": 16799.0, "90th_percentile": 16799.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 10944.55, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 10944.55, "10th_percentile": 10944.55, "90th_percentile": 10944.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9390.64, "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": 9390.64, "10th_percentile": 9390.64, "90th_percentile": 9390.64, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10583.37, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10583.37, "10th_percentile": 10583.37, "90th_percentile": 10583.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 13724.78, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13724.78, "10th_percentile": 13724.78, "90th_percentile": 13724.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10146.6, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10146.6, "10th_percentile": 10146.6, "90th_percentile": 10146.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10146.6, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10146.6, "10th_percentile": 10146.6, "90th_percentile": 10146.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 3191.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3191.81, "10th_percentile": 3191.81, "90th_percentile": 3191.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3191.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3191.81, "10th_percentile": 3191.81, "90th_percentile": 3191.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 3191.81, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 3191.81, "10th_percentile": 3191.81, "90th_percentile": 3191.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1159.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1159.13, "10th_percentile": 1159.13, "90th_percentile": 1159.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1159.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1159.13, "10th_percentile": 1159.13, "90th_percentile": 1159.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1159.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1159.13, "10th_percentile": 1159.13, "90th_percentile": 1159.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1159.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1159.13, "10th_percentile": 1159.13, "90th_percentile": 1159.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1159.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1159.13, "10th_percentile": 1159.13, "90th_percentile": 1159.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 1159.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 1159.13, "10th_percentile": 1159.13, "90th_percentile": 1159.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Esd - Esophagus Ster Technique", "code_information": [ { "code": "PX-75000268", "type": "CDM" }, { "code": "43499", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 356.25, "maximum": 5163.0, "setting": "outpatient", "gross_charge": 5163.0, "discounted_cash": 3614.1, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3363.69, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3363.69, "10th_percentile": 3363.69, "90th_percentile": 3363.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2886.12, "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": 2886.12, "10th_percentile": 2886.12, "90th_percentile": 2886.12, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3252.69, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3252.69, "10th_percentile": 3252.69, "90th_percentile": 3252.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4218.17, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4218.17, "10th_percentile": 4218.17, "90th_percentile": 4218.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3118.45, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3118.45, "10th_percentile": 3118.45, "90th_percentile": 3118.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3118.45, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3118.45, "10th_percentile": 3118.45, "90th_percentile": 3118.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 4388.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4388.55, "10th_percentile": 4388.55, "90th_percentile": 4388.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4388.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 4388.55, "10th_percentile": 4388.55, "90th_percentile": 4388.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2493.73, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2493.73, "10th_percentile": 2493.73, "90th_percentile": 2493.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2338.84, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2338.84, "10th_percentile": 2338.84, "90th_percentile": 2338.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3479.86, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3479.86, "10th_percentile": 3479.86, "90th_percentile": 3479.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4218.17, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4218.17, "10th_percentile": 4218.17, "90th_percentile": 4218.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3363.69, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3363.69, "10th_percentile": 3363.69, "90th_percentile": 3363.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2806.09, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2806.09, "10th_percentile": 2806.09, "90th_percentile": 2806.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 4517.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 4517.63, "10th_percentile": 4517.63, "90th_percentile": 4517.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 3872.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 3872.25, "10th_percentile": 3872.25, "90th_percentile": 3872.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2323.35, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2323.35, "10th_percentile": 2323.35, "90th_percentile": 2323.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2591.83, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2591.83, "10th_percentile": 2591.83, "90th_percentile": 2591.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3454.05, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3454.05, "10th_percentile": 3454.05, "90th_percentile": 3454.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5163.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5163.0, "10th_percentile": 5163.0, "90th_percentile": 5163.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1311.4, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1311.4, "10th_percentile": 1311.4, "90th_percentile": 1311.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1796.72, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1796.72, "10th_percentile": 1796.72, "90th_percentile": 1796.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 3577.96, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3577.96, "10th_percentile": 3577.96, "90th_percentile": 3577.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3376.6, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3376.6, "10th_percentile": 3376.6, "90th_percentile": 3376.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5163.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5163.0, "10th_percentile": 5163.0, "90th_percentile": 5163.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5163.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5163.0, "10th_percentile": 5163.0, "90th_percentile": 5163.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 980.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 980.97, "10th_percentile": 980.97, "90th_percentile": 980.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 980.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 980.97, "10th_percentile": 980.97, "90th_percentile": 980.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 980.97, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 980.97, "10th_percentile": 980.97, "90th_percentile": 980.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.25, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.25, "10th_percentile": 356.25, "90th_percentile": 356.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.25, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.25, "10th_percentile": 356.25, "90th_percentile": 356.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.25, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.25, "10th_percentile": 356.25, "90th_percentile": 356.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.25, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.25, "10th_percentile": 356.25, "90th_percentile": 356.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.25, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.25, "10th_percentile": 356.25, "90th_percentile": 356.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 356.25, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 356.25, "10th_percentile": 356.25, "90th_percentile": 356.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." } ] } ] }, { "description": "HB Esophagoscop Stent Placement", "code_information": [ { "code": "PX-75000005", "type": "CDM" }, { "code": "43212", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 1219.04, "maximum": 6416.0, "setting": "outpatient", "gross_charge": 6416.0, "discounted_cash": 4491.2, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1219.04, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1219.04, "10th_percentile": 1219.04, "90th_percentile": 1219.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1219.04, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1219.04, "10th_percentile": 1219.04, "90th_percentile": 1219.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1219.04, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1219.04, "10th_percentile": 1219.04, "90th_percentile": 1219.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 5241.87, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5241.87, "10th_percentile": 5241.87, "90th_percentile": 5241.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2906.45, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2906.45, "10th_percentile": 2906.45, "90th_percentile": 2906.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 3098.93, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3098.93, "10th_percentile": 3098.93, "90th_percentile": 3098.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 4180.02, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4180.02, "10th_percentile": 4180.02, "90th_percentile": 4180.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4812.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4812.0, "10th_percentile": 4812.0, "90th_percentile": 4812.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 4324.38, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 4324.38, "10th_percentile": 4324.38, "90th_percentile": 4324.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 5614.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 5614.0, "10th_percentile": 5614.0, "90th_percentile": 5614.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3487.1, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3487.1, "10th_percentile": 3487.1, "90th_percentile": 3487.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2887.2, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2887.2, "10th_percentile": 2887.2, "90th_percentile": 2887.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 5453.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 5453.6, "10th_percentile": 5453.6, "90th_percentile": 5453.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 5453.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 5453.6, "10th_percentile": 5453.6, "90th_percentile": 5453.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6416.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6416.0, "10th_percentile": 6416.0, "90th_percentile": 6416.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 3220.83, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3220.83, "10th_percentile": 3220.83, "90th_percentile": 3220.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 4292.3, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4292.3, "10th_percentile": 4292.3, "90th_percentile": 4292.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 4446.29, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4446.29, "10th_percentile": 4446.29, "90th_percentile": 4446.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 4196.06, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4196.06, "10th_percentile": 4196.06, "90th_percentile": 4196.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2232.77, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2232.77, "10th_percentile": 2232.77, "90th_percentile": 2232.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1629.66, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1629.66, "10th_percentile": 1629.66, "90th_percentile": 1629.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6416.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6416.0, "10th_percentile": 6416.0, "90th_percentile": 6416.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6416.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6416.0, "10th_percentile": 6416.0, "90th_percentile": 6416.0, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3875.26, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3875.26, "10th_percentile": 3875.26, "90th_percentile": 3875.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3875.26, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3875.26, "10th_percentile": 3875.26, "90th_percentile": 3875.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3586.54, "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": 3586.54, "10th_percentile": 3586.54, "90th_percentile": 3586.54, "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": "VWH BCBS HMO", "standard_charge_dollar": 4180.02, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4180.02, "10th_percentile": 4180.02, "90th_percentile": 4180.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 5241.87, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5241.87, "10th_percentile": 5241.87, "90th_percentile": 5241.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4042.08, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4042.08, "10th_percentile": 4042.08, "90th_percentile": 4042.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Evaluate Pt Use of Inhaler", "code_information": [ { "code": "PX-41000009", "type": "CDM" }, { "code": "94664", "type": "CPT" }, { "code": "0410", "type": "RC" } ], "standard_charges": [ { "minimum": 68.78, "maximum": 362.0, "setting": "outpatient", "gross_charge": 362.0, "discounted_cash": 253.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 218.65, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 218.65, "10th_percentile": 218.65, "90th_percentile": 218.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 218.65, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 218.65, "10th_percentile": 218.65, "90th_percentile": 218.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 235.84, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 235.84, "10th_percentile": 235.84, "90th_percentile": 235.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 202.36, "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": 202.36, "10th_percentile": 202.36, "90th_percentile": 202.36, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 228.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 228.06, "10th_percentile": 228.06, "90th_percentile": 228.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 295.75, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.75, "10th_percentile": 295.75, "90th_percentile": 295.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 68.78, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 68.78, "10th_percentile": 68.78, "90th_percentile": 68.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 68.78, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 68.78, "10th_percentile": 68.78, "90th_percentile": 68.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 68.78, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 68.78, "10th_percentile": 68.78, "90th_percentile": 68.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 362.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 362.0, "10th_percentile": 362.0, "90th_percentile": 362.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 362.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 362.0, "10th_percentile": 362.0, "90th_percentile": 362.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 236.75, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 236.75, "10th_percentile": 236.75, "90th_percentile": 236.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 91.95, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 91.95, "10th_percentile": 91.95, "90th_percentile": 91.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 250.87, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.87, "10th_percentile": 250.87, "90th_percentile": 250.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 125.98, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 125.98, "10th_percentile": 125.98, "90th_percentile": 125.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 362.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 362.0, "10th_percentile": 362.0, "90th_percentile": 362.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 316.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 316.75, "10th_percentile": 316.75, "90th_percentile": 316.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 235.84, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 235.84, "10th_percentile": 235.84, "90th_percentile": 235.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 196.75, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 196.75, "10th_percentile": 196.75, "90th_percentile": 196.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 243.99, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 243.99, "10th_percentile": 243.99, "90th_percentile": 243.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 271.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 271.5, "10th_percentile": 271.5, "90th_percentile": 271.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 307.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 307.7, "10th_percentile": 307.7, "90th_percentile": 307.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 162.9, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 162.9, "10th_percentile": 162.9, "90th_percentile": 162.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 289.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 289.6, "10th_percentile": 289.6, "90th_percentile": 289.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 295.75, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.75, "10th_percentile": 295.75, "90th_percentile": 295.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 181.72, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.72, "10th_percentile": 181.72, "90th_percentile": 181.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 242.18, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 242.18, "10th_percentile": 242.18, "90th_percentile": 242.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 174.85, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.85, "10th_percentile": 174.85, "90th_percentile": 174.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 163.99, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 163.99, "10th_percentile": 163.99, "90th_percentile": 163.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Everolimus, Blood", "code_information": [ { "code": "PX-30105254", "type": "CDM" }, { "code": "80169", "type": "CPT" }, { "code": "0301", "type": "RC" } ], "standard_charges": [ { "minimum": 38.38, "maximum": 202.0, "setting": "outpatient", "gross_charge": 202.0, "discounted_cash": 141.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 122.01, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.01, "10th_percentile": 122.01, "90th_percentile": 122.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 122.01, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.01, "10th_percentile": 122.01, "90th_percentile": 122.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 131.6, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 131.6, "10th_percentile": 131.6, "90th_percentile": 131.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 112.92, "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": 112.92, "10th_percentile": 112.92, "90th_percentile": 112.92, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 127.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 127.26, "10th_percentile": 127.26, "90th_percentile": 127.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 165.03, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.03, "10th_percentile": 165.03, "90th_percentile": 165.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 171.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 171.7, "10th_percentile": 171.7, "90th_percentile": 171.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 202.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 202.0, "10th_percentile": 202.0, "90th_percentile": 202.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 161.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 161.6, "10th_percentile": 161.6, "90th_percentile": 161.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 90.9, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 90.9, "10th_percentile": 90.9, "90th_percentile": 90.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 136.15, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 136.15, "10th_percentile": 136.15, "90th_percentile": 136.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 151.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 151.5, "10th_percentile": 151.5, "90th_percentile": 151.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 176.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 176.75, "10th_percentile": 176.75, "90th_percentile": 176.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 109.79, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 109.79, "10th_percentile": 109.79, "90th_percentile": 109.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 131.6, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 131.6, "10th_percentile": 131.6, "90th_percentile": 131.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 165.03, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.03, "10th_percentile": 165.03, "90th_percentile": 165.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 51.31, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 51.31, "10th_percentile": 51.31, "90th_percentile": 51.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 70.3, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 70.3, "10th_percentile": 70.3, "90th_percentile": 70.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 139.99, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.99, "10th_percentile": 139.99, "90th_percentile": 139.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 202.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 202.0, "10th_percentile": 202.0, "90th_percentile": 202.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 202.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 202.0, "10th_percentile": 202.0, "90th_percentile": 202.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 38.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 38.38, "10th_percentile": 38.38, "90th_percentile": 38.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 38.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 38.38, "10th_percentile": 38.38, "90th_percentile": 38.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 38.38, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 38.38, "10th_percentile": 38.38, "90th_percentile": 38.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Exc Tr-Ext Mal+Marg >4 Cm", "code_information": [ { "code": "PX-36100052", "type": "CDM" }, { "code": "11606", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 1720.83, "maximum": 9057.0, "setting": "outpatient", "gross_charge": 9057.0, "discounted_cash": 6339.9, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5705.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5705.91, "10th_percentile": 5705.91, "90th_percentile": 5705.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 7399.57, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7399.57, "10th_percentile": 7399.57, "90th_percentile": 7399.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5470.43, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5470.43, "10th_percentile": 5470.43, "90th_percentile": 5470.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5470.43, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5470.43, "10th_percentile": 5470.43, "90th_percentile": 5470.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5062.86, "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": 5062.86, "10th_percentile": 5062.86, "90th_percentile": 5062.86, "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 7399.57, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7399.57, "10th_percentile": 7399.57, "90th_percentile": 7399.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 4102.82, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4102.82, "10th_percentile": 4102.82, "90th_percentile": 4102.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 4374.53, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4374.53, "10th_percentile": 4374.53, "90th_percentile": 4374.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 7698.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 7698.45, "10th_percentile": 7698.45, "90th_percentile": 7698.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 6792.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 6792.75, "10th_percentile": 6792.75, "90th_percentile": 6792.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 4922.48, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 4922.48, "10th_percentile": 4922.48, "90th_percentile": 4922.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 6104.42, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 6104.42, "10th_percentile": 6104.42, "90th_percentile": 6104.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 7924.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 7924.88, "10th_percentile": 7924.88, "90th_percentile": 7924.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 7245.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 7245.6, "10th_percentile": 7245.6, "90th_percentile": 7245.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 4075.65, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 4075.65, "10th_percentile": 4075.65, "90th_percentile": 4075.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 2300.48, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 2300.48, "10th_percentile": 2300.48, "90th_percentile": 2300.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 3151.84, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 3151.84, "10th_percentile": 3151.84, "90th_percentile": 3151.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 6276.5, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6276.5, "10th_percentile": 6276.5, "90th_percentile": 6276.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 5923.28, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5923.28, "10th_percentile": 5923.28, "90th_percentile": 5923.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 1720.83, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1720.83, "10th_percentile": 1720.83, "90th_percentile": 1720.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1720.83, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1720.83, "10th_percentile": 1720.83, "90th_percentile": 1720.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1720.83, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1720.83, "10th_percentile": 1720.83, "90th_percentile": 1720.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9057.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9057.0, "10th_percentile": 9057.0, "90th_percentile": 9057.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9057.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9057.0, "10th_percentile": 9057.0, "90th_percentile": 9057.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 5900.64, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 5900.64, "10th_percentile": 5900.64, "90th_percentile": 5900.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 5900.64, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 5900.64, "10th_percentile": 5900.64, "90th_percentile": 5900.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Exc Tumor Soft Tissue Abdominal Wall Subq <3cm", "code_information": [ { "code": "PX-36100902", "type": "CDM" }, { "code": "22902", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 3946.72, "maximum": 7862.0, "setting": "outpatient", "gross_charge": 7862.0, "discounted_cash": 5503.4, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7862.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7862.0, "10th_percentile": 7862.0, "90th_percentile": 7862.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 3946.72, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3946.72, "10th_percentile": 3946.72, "90th_percentile": 3946.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 5259.68, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5259.68, "10th_percentile": 5259.68, "90th_percentile": 5259.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Exc Tumor Soft Tissue Leg/Ankle Subq <3cm", "code_information": [ { "code": "PX-76100085", "type": "CDM" }, { "code": "27618", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 1901.14, "maximum": 10006.0, "setting": "outpatient", "gross_charge": 10006.0, "discounted_cash": 7004.2, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6303.78, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6303.78, "10th_percentile": 6303.78, "90th_percentile": 6303.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 8174.9, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8174.9, "10th_percentile": 8174.9, "90th_percentile": 8174.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6043.62, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6043.62, "10th_percentile": 6043.62, "90th_percentile": 6043.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6043.62, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6043.62, "10th_percentile": 6043.62, "90th_percentile": 6043.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5593.35, "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": 5593.35, "10th_percentile": 5593.35, "90th_percentile": 5593.35, "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 8174.9, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8174.9, "10th_percentile": 8174.9, "90th_percentile": 8174.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 4532.72, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4532.72, "10th_percentile": 4532.72, "90th_percentile": 4532.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 4832.9, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4832.9, "10th_percentile": 4832.9, "90th_percentile": 4832.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 8505.1, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 8505.1, "10th_percentile": 8505.1, "90th_percentile": 8505.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 7504.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 7504.5, "10th_percentile": 7504.5, "90th_percentile": 7504.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 5438.26, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 5438.26, "10th_percentile": 5438.26, "90th_percentile": 5438.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 6744.04, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 6744.04, "10th_percentile": 6744.04, "90th_percentile": 6744.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 8755.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 8755.25, "10th_percentile": 8755.25, "90th_percentile": 8755.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 8004.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 8004.8, "10th_percentile": 8004.8, "90th_percentile": 8004.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 4502.7, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 4502.7, "10th_percentile": 4502.7, "90th_percentile": 4502.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 2541.52, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 2541.52, "10th_percentile": 2541.52, "90th_percentile": 2541.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 3482.09, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 3482.09, "10th_percentile": 3482.09, "90th_percentile": 3482.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 6934.16, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6934.16, "10th_percentile": 6934.16, "90th_percentile": 6934.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 6543.92, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6543.92, "10th_percentile": 6543.92, "90th_percentile": 6543.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 1901.14, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1901.14, "10th_percentile": 1901.14, "90th_percentile": 1901.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1901.14, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1901.14, "10th_percentile": 1901.14, "90th_percentile": 1901.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1901.14, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1901.14, "10th_percentile": 1901.14, "90th_percentile": 1901.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10006.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10006.0, "10th_percentile": 10006.0, "90th_percentile": 10006.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10006.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10006.0, "10th_percentile": 10006.0, "90th_percentile": 10006.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 6518.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 6518.91, "10th_percentile": 6518.91, "90th_percentile": 6518.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 6518.91, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 6518.91, "10th_percentile": 6518.91, "90th_percentile": 6518.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Fiberoptic Intubation", "code_information": [ { "code": "PX-37000028", "type": "CDM" }, { "code": "37000028", "type": "LOCAL" }, { "code": "0370", "type": "RC" } ], "standard_charges": [ { "minimum": 169.86, "maximum": 894.0, "setting": "outpatient", "gross_charge": 894.0, "discounted_cash": 625.8, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 894.0, "10th_percentile": 894.0, "90th_percentile": 894.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 894.0, "10th_percentile": 894.0, "90th_percentile": 894.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 894.0, "10th_percentile": 894.0, "90th_percentile": 894.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 894.0, "10th_percentile": 894.0, "90th_percentile": 894.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 894.0, "10th_percentile": 894.0, "90th_percentile": 894.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 894.0, "10th_percentile": 894.0, "90th_percentile": 894.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 599.52, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 599.52, "10th_percentile": 599.52, "90th_percentile": 599.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 499.75, "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": 499.75, "10th_percentile": 499.75, "90th_percentile": 499.75, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 564.2, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 564.2, "10th_percentile": 564.2, "90th_percentile": 564.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 503.77, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 503.77, "10th_percentile": 503.77, "90th_percentile": 503.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 728.61, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 728.61, "10th_percentile": 728.61, "90th_percentile": 728.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 582.44, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 582.44, "10th_percentile": 582.44, "90th_percentile": 582.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 894.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 894.0, "10th_percentile": 894.0, "90th_percentile": 894.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 894.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 894.0, "10th_percentile": 894.0, "90th_percentile": 894.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 169.86, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 169.86, "10th_percentile": 169.86, "90th_percentile": 169.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 169.86, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 169.86, "10th_percentile": 169.86, "90th_percentile": 169.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 584.68, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 584.68, "10th_percentile": 584.68, "90th_percentile": 584.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 619.54, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 619.54, "10th_percentile": 619.54, "90th_percentile": 619.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 311.11, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 311.11, "10th_percentile": 311.11, "90th_percentile": 311.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 227.08, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 227.08, "10th_percentile": 227.08, "90th_percentile": 227.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 598.09, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 598.09, "10th_percentile": 598.09, "90th_percentile": 598.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 448.79, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.79, "10th_percentile": 448.79, "90th_percentile": 448.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 894.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 894.0, "10th_percentile": 894.0, "90th_percentile": 894.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 169.86, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 169.86, "10th_percentile": 169.86, "90th_percentile": 169.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 582.44, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 582.44, "10th_percentile": 582.44, "90th_percentile": 582.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 402.3, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 402.3, "10th_percentile": 402.3, "90th_percentile": 402.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 759.9, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 759.9, "10th_percentile": 759.9, "90th_percentile": 759.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 670.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 670.5, "10th_percentile": 670.5, "90th_percentile": 670.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 782.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 782.25, "10th_percentile": 782.25, "90th_percentile": 782.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 485.89, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 485.89, "10th_percentile": 485.89, "90th_percentile": 485.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 602.56, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 602.56, "10th_percentile": 602.56, "90th_percentile": 602.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 404.98, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 404.98, "10th_percentile": 404.98, "90th_percentile": 404.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 431.8, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 431.8, "10th_percentile": 431.8, "90th_percentile": 431.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 728.61, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 728.61, "10th_percentile": 728.61, "90th_percentile": 728.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 715.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 715.2, "10th_percentile": 715.2, "90th_percentile": 715.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" } ] } ] }, { "description": "HB Fine Needle Aspiration Bx W/CT Gdn Ea Addl", "code_information": [ { "code": "PX-76100048", "type": "CDM" }, { "code": "10010", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 660.82, "maximum": 3478.0, "setting": "outpatient", "gross_charge": 3478.0, "discounted_cash": 2434.6, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1944.2, "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": 1944.2, "10th_percentile": 1944.2, "90th_percentile": 1944.2, "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": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1575.53, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1575.53, "10th_percentile": 1575.53, "90th_percentile": 1575.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1679.87, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1679.87, "10th_percentile": 1679.87, "90th_percentile": 1679.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 2956.3, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2956.3, "10th_percentile": 2956.3, "90th_percentile": 2956.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2608.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2608.5, "10th_percentile": 2608.5, "90th_percentile": 2608.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1890.29, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1890.29, "10th_percentile": 1890.29, "90th_percentile": 1890.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2344.17, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2344.17, "10th_percentile": 2344.17, "90th_percentile": 2344.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 3043.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 3043.25, "10th_percentile": 3043.25, "90th_percentile": 3043.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2782.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2782.4, "10th_percentile": 2782.4, "90th_percentile": 2782.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1565.1, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1565.1, "10th_percentile": 1565.1, "90th_percentile": 1565.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 660.82, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 660.82, "10th_percentile": 660.82, "90th_percentile": 660.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 660.82, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 660.82, "10th_percentile": 660.82, "90th_percentile": 660.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 883.41, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 883.41, "10th_percentile": 883.41, "90th_percentile": 883.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1210.34, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1210.34, "10th_percentile": 1210.34, "90th_percentile": 1210.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2410.25, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2410.25, "10th_percentile": 2410.25, "90th_percentile": 2410.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2274.61, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2274.61, "10th_percentile": 2274.61, "90th_percentile": 2274.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 660.82, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 660.82, "10th_percentile": 660.82, "90th_percentile": 660.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3478.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3478.0, "10th_percentile": 3478.0, "90th_percentile": 3478.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3478.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3478.0, "10th_percentile": 3478.0, "90th_percentile": 3478.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 2265.92, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2265.92, "10th_percentile": 2265.92, "90th_percentile": 2265.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2265.92, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2265.92, "10th_percentile": 2265.92, "90th_percentile": 2265.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Fish, Ccnd1 Bap, 11q13, Multiplex", "code_information": [ { "code": "PX-31118150", "type": "CDM" }, { "code": "88366", "type": "CPT" }, { "code": "0311", "type": "RC" } ], "standard_charges": [ { "minimum": 173.66, "maximum": 914.0, "setting": "outpatient", "gross_charge": 914.0, "discounted_cash": 639.8, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 552.06, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.06, "10th_percentile": 552.06, "90th_percentile": 552.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 552.06, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.06, "10th_percentile": 552.06, "90th_percentile": 552.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 595.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 595.47, "10th_percentile": 595.47, "90th_percentile": 595.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 510.93, "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": 510.93, "10th_percentile": 510.93, "90th_percentile": 510.93, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 575.82, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 575.82, "10th_percentile": 575.82, "90th_percentile": 575.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 746.74, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 746.74, "10th_percentile": 746.74, "90th_percentile": 746.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 173.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 173.66, "10th_percentile": 173.66, "90th_percentile": 173.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 173.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 173.66, "10th_percentile": 173.66, "90th_percentile": 173.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 173.66, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 173.66, "10th_percentile": 173.66, "90th_percentile": 173.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 914.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 914.0, "10th_percentile": 914.0, "90th_percentile": 914.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 914.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 914.0, "10th_percentile": 914.0, "90th_percentile": 914.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 232.16, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 232.16, "10th_percentile": 232.16, "90th_percentile": 232.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 633.4, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 633.4, "10th_percentile": 633.4, "90th_percentile": 633.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 318.07, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 318.07, "10th_percentile": 318.07, "90th_percentile": 318.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 914.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 914.0, "10th_percentile": 914.0, "90th_percentile": 914.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 799.75, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 799.75, "10th_percentile": 799.75, "90th_percentile": 799.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 595.47, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 595.47, "10th_percentile": 595.47, "90th_percentile": 595.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 496.76, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 496.76, "10th_percentile": 496.76, "90th_percentile": 496.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 616.04, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 616.04, "10th_percentile": 616.04, "90th_percentile": 616.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 685.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 685.5, "10th_percentile": 685.5, "90th_percentile": 685.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 776.9, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 776.9, "10th_percentile": 776.9, "90th_percentile": 776.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 411.3, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 411.3, "10th_percentile": 411.3, "90th_percentile": 411.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 731.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 731.2, "10th_percentile": 731.2, "90th_percentile": 731.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 746.74, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 746.74, "10th_percentile": 746.74, "90th_percentile": 746.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Flowcytometry Ea Addl Marker", "code_information": [ { "code": "PX-30207010", "type": "CDM" }, { "code": "88185", "type": "CPT" }, { "code": "0311", "type": "RC" } ], "standard_charges": [ { "minimum": 30.21, "maximum": 159.0, "setting": "outpatient", "gross_charge": 159.0, "discounted_cash": 111.3, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 96.04, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 96.04, "10th_percentile": 96.04, "90th_percentile": 96.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 96.04, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 96.04, "10th_percentile": 96.04, "90th_percentile": 96.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 103.59, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 103.59, "10th_percentile": 103.59, "90th_percentile": 103.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 88.88, "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": 88.88, "10th_percentile": 88.88, "90th_percentile": 88.88, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 100.17, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.17, "10th_percentile": 100.17, "90th_percentile": 100.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 129.9, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.9, "10th_percentile": 129.9, "90th_percentile": 129.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 30.21, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 29.7, "10th_percentile": 29.7, "90th_percentile": 29.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 30.21, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 30.21, "10th_percentile": 30.21, "90th_percentile": 30.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 30.21, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 30.21, "10th_percentile": 30.21, "90th_percentile": 30.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 159.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 159.0, "10th_percentile": 159.0, "90th_percentile": 159.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 159.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 159.0, "10th_percentile": 159.0, "90th_percentile": 159.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 40.39, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 40.39, "10th_percentile": 40.39, "90th_percentile": 40.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 110.19, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 110.19, "10th_percentile": 110.19, "90th_percentile": 110.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 55.33, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 55.33, "10th_percentile": 55.33, "90th_percentile": 55.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 159.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 159.0, "10th_percentile": 159.0, "90th_percentile": 159.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 139.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 139.13, "10th_percentile": 139.13, "90th_percentile": 139.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 103.59, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 103.59, "10th_percentile": 103.59, "90th_percentile": 103.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 86.42, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 86.42, "10th_percentile": 86.42, "90th_percentile": 86.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 107.17, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 107.17, "10th_percentile": 107.17, "90th_percentile": 107.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 119.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 119.25, "10th_percentile": 119.25, "90th_percentile": 119.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 135.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 135.15, "10th_percentile": 135.15, "90th_percentile": 135.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 71.55, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 71.55, "10th_percentile": 71.55, "90th_percentile": 71.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 127.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 127.2, "10th_percentile": 127.2, "90th_percentile": 127.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 129.9, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.9, "10th_percentile": 129.9, "90th_percentile": 129.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Fracture Radius & Ulna; With Manipulation", "code_information": [ { "code": "PX-36100243", "type": "CDM" }, { "code": "25565", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 715.85, "maximum": 1426.0, "setting": "outpatient", "gross_charge": 1426.0, "discounted_cash": 998.2, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1426.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1426.0, "10th_percentile": 1426.0, "90th_percentile": 1426.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 715.85, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 715.85, "10th_percentile": 715.85, "90th_percentile": 715.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 953.99, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 953.99, "10th_percentile": 953.99, "90th_percentile": 953.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Glucose, Whole Blood, (POCT)", "code_information": [ { "code": "PX-30001310", "type": "CDM" }, { "code": "82948", "type": "CPT" }, { "code": "0301", "type": "RC" } ], "standard_charges": [ { "minimum": 10.26, "maximum": 54.0, "setting": "outpatient", "gross_charge": 54.0, "discounted_cash": 37.8, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 32.62, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.62, "10th_percentile": 32.62, "90th_percentile": 32.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 32.62, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.62, "10th_percentile": 32.62, "90th_percentile": 32.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 35.18, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 35.18, "10th_percentile": 35.18, "90th_percentile": 35.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 30.19, "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": 30.19, "10th_percentile": 30.19, "90th_percentile": 30.19, "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 34.02, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.02, "10th_percentile": 34.02, "90th_percentile": 34.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 44.12, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.12, "10th_percentile": 44.12, "90th_percentile": 44.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 45.9, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 45.9, "10th_percentile": 45.9, "90th_percentile": 45.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 54.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 54.0, "10th_percentile": 54.0, "90th_percentile": 54.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 43.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 43.2, "10th_percentile": 43.2, "90th_percentile": 43.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 24.3, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 24.3, "10th_percentile": 24.3, "90th_percentile": 24.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 36.4, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 36.4, "10th_percentile": 36.4, "90th_percentile": 36.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 40.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 40.5, "10th_percentile": 40.5, "90th_percentile": 40.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 47.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 47.25, "10th_percentile": 47.25, "90th_percentile": 47.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 29.35, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 29.35, "10th_percentile": 29.35, "90th_percentile": 29.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 35.18, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 35.18, "10th_percentile": 35.18, "90th_percentile": 35.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 44.12, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.12, "10th_percentile": 44.12, "90th_percentile": 44.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 13.72, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 13.72, "10th_percentile": 13.72, "90th_percentile": 13.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 18.79, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 18.79, "10th_percentile": 18.79, "90th_percentile": 18.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 37.42, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.42, "10th_percentile": 37.42, "90th_percentile": 37.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 54.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 54.0, "10th_percentile": 54.0, "90th_percentile": 54.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 54.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 54.0, "10th_percentile": 54.0, "90th_percentile": 54.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 10.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 10.26, "10th_percentile": 10.26, "90th_percentile": 10.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 10.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 10.26, "10th_percentile": 10.26, "90th_percentile": 10.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 10.26, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 10.26, "10th_percentile": 10.26, "90th_percentile": 10.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Heated High Flow Oxygen", "code_information": [ { "code": "PX-41000017", "type": "CDM" }, { "code": "41000017", "type": "LOCAL" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "minimum": 90.44, "maximum": 476.0, "setting": "outpatient", "gross_charge": 476.0, "discounted_cash": 333.2, "payers_information": [ { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.0, "10th_percentile": 476.0, "90th_percentile": 476.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.0, "10th_percentile": 476.0, "90th_percentile": 476.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.0, "10th_percentile": 476.0, "90th_percentile": 476.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.0, "10th_percentile": 476.0, "90th_percentile": 476.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.0, "10th_percentile": 476.0, "90th_percentile": 476.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 476.0, "10th_percentile": 476.0, "90th_percentile": 476.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 320.82, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 320.82, "10th_percentile": 320.82, "90th_percentile": 320.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 404.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 404.6, "10th_percentile": 404.6, "90th_percentile": 404.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 258.71, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 258.71, "10th_percentile": 258.71, "90th_percentile": 258.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 357.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 357.0, "10th_percentile": 357.0, "90th_percentile": 357.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 229.91, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.91, "10th_percentile": 229.91, "90th_percentile": 229.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 214.2, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 214.2, "10th_percentile": 214.2, "90th_percentile": 214.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 215.63, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.63, "10th_percentile": 215.63, "90th_percentile": 215.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 380.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 380.8, "10th_percentile": 380.8, "90th_percentile": 380.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 387.94, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 387.94, "10th_percentile": 387.94, "90th_percentile": 387.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 310.11, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 310.11, "10th_percentile": 310.11, "90th_percentile": 310.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 90.44, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 90.44, "10th_percentile": 90.44, "90th_percentile": 90.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 416.5, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 416.5, "10th_percentile": 416.5, "90th_percentile": 416.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 238.95, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 238.95, "10th_percentile": 238.95, "90th_percentile": 238.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 318.44, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 318.44, "10th_percentile": 318.44, "90th_percentile": 318.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 476.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 476.0, "10th_percentile": 476.0, "90th_percentile": 476.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 311.3, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 311.3, "10th_percentile": 311.3, "90th_percentile": 311.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 329.87, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 329.87, "10th_percentile": 329.87, "90th_percentile": 329.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 165.65, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 165.65, "10th_percentile": 165.65, "90th_percentile": 165.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 120.9, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 120.9, "10th_percentile": 120.9, "90th_percentile": 120.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 90.44, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 90.44, "10th_percentile": 90.44, "90th_percentile": 90.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 90.44, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 90.44, "10th_percentile": 90.44, "90th_percentile": 90.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 476.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 476.0, "10th_percentile": 476.0, "90th_percentile": 476.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 476.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 476.0, "10th_percentile": 476.0, "90th_percentile": 476.0, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 319.21, "standard_charge_percentage": 67.06, "standard_charge_algorithm": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 319.21, "10th_percentile": 319.21, "90th_percentile": 319.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 67.06% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 300.4, "standard_charge_percentage": 63.11, "standard_charge_algorithm": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 300.4, "10th_percentile": 300.4, "90th_percentile": 300.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 63.11% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 266.08, "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": 266.08, "10th_percentile": 266.08, "90th_percentile": 266.08, "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": "VWH BCBS PPO", "standard_charge_dollar": 387.94, "standard_charge_percentage": 81.5, "standard_charge_algorithm": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 387.94, "10th_percentile": 387.94, "90th_percentile": 387.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 81.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 268.23, "standard_charge_percentage": 56.35, "standard_charge_algorithm": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 268.23, "10th_percentile": 268.23, "90th_percentile": 268.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other; 56.35% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 310.11, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 310.11, "10th_percentile": 310.11, "90th_percentile": 310.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Hepatic Pressure WO Venography - Unlisted", "code_information": [ { "code": "PX-32000398", "type": "CDM" }, { "code": "76496", "type": "CPT" }, { "code": "0320", "type": "RC" } ], "standard_charges": [ { "minimum": 556.83, "maximum": 8070.0, "setting": "outpatient", "gross_charge": 8070.0, "discounted_cash": 5649.0, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4874.28, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4874.28, "10th_percentile": 4874.28, "90th_percentile": 4874.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4874.28, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4874.28, "10th_percentile": 4874.28, "90th_percentile": 4874.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 5257.61, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 5257.61, "10th_percentile": 5257.61, "90th_percentile": 5257.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4511.13, "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": 4511.13, "10th_percentile": 4511.13, "90th_percentile": 4511.13, "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5084.1, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5084.1, "10th_percentile": 5084.1, "90th_percentile": 5084.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 6593.19, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6593.19, "10th_percentile": 6593.19, "90th_percentile": 6593.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1533.3, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1533.3, "10th_percentile": 1533.3, "90th_percentile": 1533.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1533.3, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1533.3, "10th_percentile": 1533.3, "90th_percentile": 1533.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1533.3, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1533.3, "10th_percentile": 1533.3, "90th_percentile": 1533.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8070.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8070.0, "10th_percentile": 8070.0, "90th_percentile": 8070.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8070.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8070.0, "10th_percentile": 8070.0, "90th_percentile": 8070.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 5277.78, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5277.78, "10th_percentile": 5277.78, "90th_percentile": 5277.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 2049.78, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 2049.78, "10th_percentile": 2049.78, "90th_percentile": 2049.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 5592.51, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5592.51, "10th_percentile": 5592.51, "90th_percentile": 5592.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2808.36, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2808.36, "10th_percentile": 2808.36, "90th_percentile": 2808.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8070.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8070.0, "10th_percentile": 8070.0, "90th_percentile": 8070.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 7061.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 7061.25, "10th_percentile": 7061.25, "90th_percentile": 7061.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 5257.61, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 5257.61, "10th_percentile": 5257.61, "90th_percentile": 5257.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 4386.05, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 4386.05, "10th_percentile": 4386.05, "90th_percentile": 4386.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 5439.18, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 5439.18, "10th_percentile": 5439.18, "90th_percentile": 5439.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 6052.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 6052.5, "10th_percentile": 6052.5, "90th_percentile": 6052.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 6859.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 6859.5, "10th_percentile": 6859.5, "90th_percentile": 6859.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 3631.5, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 3631.5, "10th_percentile": 3631.5, "90th_percentile": 3631.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 6456.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 6456.0, "10th_percentile": 6456.0, "90th_percentile": 6456.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 556.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 556.83, "10th_percentile": 556.83, "90th_percentile": 556.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 556.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 556.83, "10th_percentile": 556.83, "90th_percentile": 556.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 556.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 556.83, "10th_percentile": 556.83, "90th_percentile": 556.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 556.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 556.83, "10th_percentile": 556.83, "90th_percentile": 556.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 556.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 556.83, "10th_percentile": 556.83, "90th_percentile": 556.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 556.83, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 556.83, "10th_percentile": 556.83, "90th_percentile": 556.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 6593.19, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6593.19, "10th_percentile": 6593.19, "90th_percentile": 6593.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Herpes Simplex Virus Type 2, Pcr", "code_information": [ { "code": "PX-30209292", "type": "CDM" }, { "code": "87529", "type": "CPT" }, { "code": "0306", "type": "RC" } ], "standard_charges": [ { "minimum": 53.39, "maximum": 281.0, "setting": "outpatient", "gross_charge": 281.0, "discounted_cash": 196.7, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 281.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 281.0, "10th_percentile": 281.0, "90th_percentile": 281.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 281.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 281.0, "10th_percentile": 281.0, "90th_percentile": 281.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 229.58, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.58, "10th_percentile": 229.58, "90th_percentile": 229.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 126.45, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 126.45, "10th_percentile": 126.45, "90th_percentile": 126.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 189.39, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 189.39, "10th_percentile": 189.39, "90th_percentile": 189.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 245.88, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 245.88, "10th_percentile": 245.88, "90th_percentile": 245.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 238.85, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 238.85, "10th_percentile": 238.85, "90th_percentile": 238.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 183.07, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 183.07, "10th_percentile": 183.07, "90th_percentile": 183.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 281.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 281.0, "10th_percentile": 281.0, "90th_percentile": 281.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 152.72, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 152.72, "10th_percentile": 152.72, "90th_percentile": 152.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 224.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 224.8, "10th_percentile": 224.8, "90th_percentile": 224.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 210.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 210.75, "10th_percentile": 210.75, "90th_percentile": 210.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 194.73, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.73, "10th_percentile": 194.73, "90th_percentile": 194.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 97.79, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 97.79, "10th_percentile": 97.79, "90th_percentile": 97.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 71.37, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 71.37, "10th_percentile": 71.37, "90th_percentile": 71.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 229.58, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.58, "10th_percentile": 229.58, "90th_percentile": 229.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 177.03, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.03, "10th_percentile": 177.03, "90th_percentile": 177.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 183.07, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 183.07, "10th_percentile": 183.07, "90th_percentile": 183.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 157.08, "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": 157.08, "10th_percentile": 157.08, "90th_percentile": 157.08, "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": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 169.72, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.72, "10th_percentile": 169.72, "90th_percentile": 169.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 169.72, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.72, "10th_percentile": 169.72, "90th_percentile": 169.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 53.39, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 53.39, "10th_percentile": 53.39, "90th_percentile": 53.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 53.39, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 53.39, "10th_percentile": 53.39, "90th_percentile": 53.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 53.39, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 53.39, "10th_percentile": 53.39, "90th_percentile": 53.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" } ] } ] }, { "description": "HB Hospital Observation per Hr", "code_information": [ { "code": "PX-76200004", "type": "CDM" }, { "code": "G0378", "type": "HCPCS" }, { "code": "0762", "type": "RC" } ], "standard_charges": [ { "minimum": 5.52, "maximum": 80.0, "setting": "outpatient", "gross_charge": 80.0, "discounted_cash": 56.0, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 20.32, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 27.05, "10th_percentile": 27.05, "90th_percentile": 27.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 53.52, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Observation; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 472.25, "10th_percentile": 472.25, "90th_percentile": 472.25, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 630.11, "10th_percentile": 630.11, "90th_percentile": 630.11, "count": "29", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 630.11, "10th_percentile": 630.11, "90th_percentile": 630.11, "count": "29", "methodology": "percent of total billed charges" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 630.11, "10th_percentile": 630.11, "90th_percentile": 630.11, "count": "29", "methodology": "percent of total billed charges" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 630.11, "10th_percentile": 630.11, "90th_percentile": 630.11, "count": "29", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 630.11, "10th_percentile": 630.11, "90th_percentile": 630.11, "count": "29", "methodology": "percent of total billed charges" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.52, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "ProFees 1500 - Default; 6.9% Billed, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 630.11, "10th_percentile": 630.11, "90th_percentile": 630.11, "count": "29", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 70.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 70.0, "10th_percentile": 70.0, "90th_percentile": 70.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 36.0, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 36.0, "10th_percentile": 36.0, "90th_percentile": 36.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 68.0, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 68.0, "10th_percentile": 68.0, "90th_percentile": 68.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 43.48, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 43.48, "10th_percentile": 43.48, "90th_percentile": 43.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 60.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 60.0, "10th_percentile": 60.0, "90th_percentile": 60.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 53.92, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 53.92, "10th_percentile": 53.92, "90th_percentile": 53.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 52.12, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 52.12, "10th_percentile": 52.12, "90th_percentile": 52.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 80.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 80.0, "10th_percentile": 80.0, "90th_percentile": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 64.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 64.0, "10th_percentile": 64.0, "90th_percentile": 64.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 65.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.36, "10th_percentile": 65.36, "90th_percentile": 65.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 40.16, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Observation; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.16, "10th_percentile": 40.16, "90th_percentile": 40.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Observation; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 36.24, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Observation; 45.3% Billed, and; Pricing Extension - NM HB XR PRC - PERCENT OF CHARGES NTE $3,200 EXCLUDING CARV*", "median_amount": 36.24, "10th_percentile": 36.24, "90th_percentile": 36.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Observation; 45.3% Billed, and; Pricing Extension - NM HB XR PRC - PERCENT OF CHARGES NTE $3,200 EXCLUDING CARV*" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 38.64, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Observation; 48.3% Billed, and; Pricing Extension - NM HB XR PRC - PERCENT OF CHARGES NTE $14,963 EXCLUDING CAR*", "median_amount": 38.64, "10th_percentile": 38.64, "90th_percentile": 38.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Observation; 48.3% Billed, and; Pricing Extension - NM HB XR PRC - PERCENT OF CHARGES NTE $14,963 EXCLUDING CAR*" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 52.32, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.32, "10th_percentile": 52.32, "90th_percentile": 52.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 55.44, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.44, "10th_percentile": 55.44, "90th_percentile": 55.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 27.84, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 27.84, "10th_percentile": 27.84, "90th_percentile": 27.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 80.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 80.0, "10th_percentile": 80.0, "90th_percentile": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 80.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 80.0, "10th_percentile": 80.0, "90th_percentile": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 15.2, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 15.2, "10th_percentile": 15.2, "90th_percentile": 15.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 15.2, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 15.2, "10th_percentile": 15.2, "90th_percentile": 15.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 15.2, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 15.2, "10th_percentile": 15.2, "90th_percentile": 15.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 65.36, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.36, "10th_percentile": 65.36, "90th_percentile": 65.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 50.4, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.4, "10th_percentile": 50.4, "90th_percentile": 50.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 44.72, "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": 44.72, "10th_percentile": 44.72, "90th_percentile": 44.72, "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": "VWH BCBS HMO", "standard_charge_dollar": 52.12, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 52.12, "10th_percentile": 52.12, "90th_percentile": 52.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 48.32, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.32, "10th_percentile": 48.32, "90th_percentile": 48.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 48.32, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.32, "10th_percentile": 48.32, "90th_percentile": 48.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Hyperthermia Treatment, Externally; Superficial", "code_information": [ { "code": "PX-33300050", "type": "CDM" }, { "code": "77600", "type": "CPT" }, { "code": "0333", "type": "RC" } ], "standard_charges": [ { "minimum": 1740.4, "maximum": 9160.0, "setting": "outpatient", "gross_charge": 9160.0, "discounted_cash": 6412.0, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5532.64, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5532.64, "10th_percentile": 5532.64, "90th_percentile": 5532.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5532.64, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5532.64, "10th_percentile": 5532.64, "90th_percentile": 5532.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 5967.74, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 5967.74, "10th_percentile": 5967.74, "90th_percentile": 5967.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5120.44, "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": 5120.44, "10th_percentile": 5120.44, "90th_percentile": 5120.44, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5770.8, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5770.8, "10th_percentile": 5770.8, "90th_percentile": 5770.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 7483.72, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7483.72, "10th_percentile": 7483.72, "90th_percentile": 7483.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1740.4, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1740.4, "10th_percentile": 1740.4, "90th_percentile": 1740.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1740.4, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1740.4, "10th_percentile": 1740.4, "90th_percentile": 1740.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1740.4, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1740.4, "10th_percentile": 1740.4, "90th_percentile": 1740.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9160.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9160.0, "10th_percentile": 9160.0, "90th_percentile": 9160.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9160.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9160.0, "10th_percentile": 9160.0, "90th_percentile": 9160.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 5990.64, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5990.64, "10th_percentile": 5990.64, "90th_percentile": 5990.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 2326.64, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 2326.64, "10th_percentile": 2326.64, "90th_percentile": 2326.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 6347.88, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6347.88, "10th_percentile": 6347.88, "90th_percentile": 6347.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 3187.68, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 3187.68, "10th_percentile": 3187.68, "90th_percentile": 3187.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9160.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 9160.0, "10th_percentile": 9160.0, "90th_percentile": 9160.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 8015.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 8015.0, "10th_percentile": 8015.0, "90th_percentile": 8015.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 5967.74, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 5967.74, "10th_percentile": 5967.74, "90th_percentile": 5967.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 4978.46, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 4978.46, "10th_percentile": 4978.46, "90th_percentile": 4978.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 6173.84, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 6173.84, "10th_percentile": 6173.84, "90th_percentile": 6173.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 6870.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 6870.0, "10th_percentile": 6870.0, "90th_percentile": 6870.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 7786.0, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 7786.0, "10th_percentile": 7786.0, "90th_percentile": 7786.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 4122.0, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 4122.0, "10th_percentile": 4122.0, "90th_percentile": 4122.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 7328.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 7328.0, "10th_percentile": 7328.0, "90th_percentile": 7328.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 7483.72, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7483.72, "10th_percentile": 7483.72, "90th_percentile": 7483.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 4598.32, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4598.32, "10th_percentile": 4598.32, "90th_percentile": 4598.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 6128.04, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6128.04, "10th_percentile": 6128.04, "90th_percentile": 6128.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB I&D Below Fascia Foot 1 Bursal Space", "code_information": [ { "code": "PX-36000564", "type": "CDM" }, { "code": "28002", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 3864.9, "maximum": 7699.0, "setting": "outpatient", "gross_charge": 7699.0, "discounted_cash": 5389.3, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7699.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7699.0, "10th_percentile": 7699.0, "90th_percentile": 7699.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 3864.9, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3864.9, "10th_percentile": 3864.9, "90th_percentile": 3864.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 5150.63, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5150.63, "10th_percentile": 5150.63, "90th_percentile": 5150.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Ihc Stain, 1st, Group 1", "code_information": [ { "code": "CASE-88342", "type": "LOCAL" }, { "code": "88342", "type": "CPT" }, { "code": "0312", "type": "RC" } ], "standard_charges": [ { "minimum": 5.65, "maximum": 5.65, "setting": "outpatient", "gross_charge": 16835.47, "discounted_cash": 11784.83, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 11010.41, "10th_percentile": 11010.41, "90th_percentile": 11010.41, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 11666.98, "10th_percentile": 11666.98, "90th_percentile": 11666.98, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_percentage": 34.8, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 5858.74, "10th_percentile": 5858.74, "90th_percentile": 5858.74, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_percentage": 25.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 4276.21, "10th_percentile": 4276.21, "90th_percentile": 4276.21, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 3198.75, "10th_percentile": 3198.75, "90th_percentile": 3198.75, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 10968.3, "10th_percentile": 10968.3, "90th_percentile": 10968.3, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 81.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 13754.59, "10th_percentile": 13754.59, "90th_percentile": 13754.59, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 3198.75, "10th_percentile": 3198.75, "90th_percentile": 3198.75, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 60.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 10168.64, "10th_percentile": 10168.64, "90th_percentile": 10168.64, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 10606.36, "10th_percentile": 10606.36, "90th_percentile": 10606.36, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 60.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 10168.64, "10th_percentile": 10168.64, "90th_percentile": 10168.64, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 10968.3, "10th_percentile": 10968.3, "90th_percentile": 10968.3, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH 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": 9411.02, "10th_percentile": 9411.02, "90th_percentile": 9411.02, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 81.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 13754.59, "10th_percentile": 13754.59, "90th_percentile": 13754.59, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 11347.11, "10th_percentile": 11347.11, "90th_percentile": 11347.11, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 7341.79, "10th_percentile": 7341.79, "90th_percentile": 7341.79, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 7827.46, "10th_percentile": 7827.46, "90th_percentile": 7827.46, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH 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": 16835.47, "10th_percentile": 16835.47, "90th_percentile": 16835.47, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 3198.75, "10th_percentile": 3198.75, "90th_percentile": 3198.75, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 14310.16, "10th_percentile": 14310.16, "90th_percentile": 14310.16, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_percentage": 45.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 7575.98, "10th_percentile": 7575.98, "90th_percentile": 7575.98, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 12626.62, "10th_percentile": 12626.62, "90th_percentile": 12626.62, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_percentage": 87.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 14731.06, "10th_percentile": 14731.06, "90th_percentile": 14731.06, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH 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": 16835.47, "10th_percentile": 16835.47, "90th_percentile": 16835.47, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 13990.67, "10th_percentile": 13990.67, "90th_percentile": 13990.67, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 9150.07, "10th_percentile": 9150.07, "90th_percentile": 9150.07, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 8138.33, "10th_percentile": 8138.33, "90th_percentile": 8138.33, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 10841.87, "10th_percentile": 10841.87, "90th_percentile": 10841.87, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH 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": 16835.47, "10th_percentile": 16835.47, "90th_percentile": 16835.47, "count": "507", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.65, "standard_charge_algorithm": "Re-evaluated: HLB.828608314; Using new claim; Scope: All Financial Classes; Cases: 507; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 5.65, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 905.22, "10th_percentile": 905.22, "90th_percentile": 905.22, "count": "507", "methodology": "fee schedule" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.65, "standard_charge_algorithm": "Re-evaluated: HLB.828608314; Using new claim; Scope: All Financial Classes; Cases: 507; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 5.65, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 905.22, "10th_percentile": 905.22, "90th_percentile": 905.22, "count": "507", "methodology": "fee schedule" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.65, "standard_charge_algorithm": "Re-evaluated: HLB.828608314; Using new claim; Scope: All Financial Classes; Cases: 507; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 5.65, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 905.22, "10th_percentile": 905.22, "90th_percentile": 905.22, "count": "507", "methodology": "fee schedule" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.65, "standard_charge_algorithm": "Re-evaluated: HLB.828608314; Using new claim; Scope: All Financial Classes; Cases: 507; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 5.65, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 905.22, "10th_percentile": 905.22, "90th_percentile": 905.22, "count": "507", "methodology": "fee schedule" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.65, "standard_charge_algorithm": "Re-evaluated: HLB.828608314; Using new claim; Scope: All Financial Classes; Cases: 507; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 5.65, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 905.22, "10th_percentile": 905.22, "90th_percentile": 905.22, "count": "507", "methodology": "fee schedule" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_dollar": 5.65, "standard_charge_algorithm": "Re-evaluated: HLB.828608314; Using new claim; Scope: All Financial Classes; Cases: 507; ProFees 1500; FSC: NM HB XR MEDICAID PROF FSC, Value: 5.65, and; Pricing Extension - HB XR PRC - LESSER OF TERMS OR CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 905.22, "10th_percentile": 905.22, "90th_percentile": 905.22, "count": "507", "methodology": "fee schedule" } ] } ] }, { "description": "HB Incision Drainage Lacrimal Sac", "code_information": [ { "code": "PX-76100640", "type": "CDM" }, { "code": "68420", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 1285.16, "maximum": 6764.0, "setting": "outpatient", "gross_charge": 6764.0, "discounted_cash": 4734.8, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3781.08, "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": 3781.08, "10th_percentile": 3781.08, "90th_percentile": 3781.08, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 3064.09, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3064.09, "10th_percentile": 3064.09, "90th_percentile": 3064.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 3267.01, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3267.01, "10th_percentile": 3267.01, "90th_percentile": 3267.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 5749.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 5749.4, "10th_percentile": 5749.4, "90th_percentile": 5749.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 5073.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 5073.0, "10th_percentile": 5073.0, "90th_percentile": 5073.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3676.23, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3676.23, "10th_percentile": 3676.23, "90th_percentile": 3676.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 4558.94, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 4558.94, "10th_percentile": 4558.94, "90th_percentile": 4558.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 5918.5, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 5918.5, "10th_percentile": 5918.5, "90th_percentile": 5918.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 5411.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 5411.2, "10th_percentile": 5411.2, "90th_percentile": 5411.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 3043.8, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 3043.8, "10th_percentile": 3043.8, "90th_percentile": 3043.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1285.16, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1285.16, "10th_percentile": 1285.16, "90th_percentile": 1285.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1285.16, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 1285.16, "10th_percentile": 1285.16, "90th_percentile": 1285.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1718.06, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1718.06, "10th_percentile": 1718.06, "90th_percentile": 1718.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2353.87, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2353.87, "10th_percentile": 2353.87, "90th_percentile": 2353.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 4687.45, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4687.45, "10th_percentile": 4687.45, "90th_percentile": 4687.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 4423.66, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4423.66, "10th_percentile": 4423.66, "90th_percentile": 4423.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1285.16, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1285.16, "10th_percentile": 1285.16, "90th_percentile": 1285.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6764.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6764.0, "10th_percentile": 6764.0, "90th_percentile": 6764.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6764.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6764.0, "10th_percentile": 6764.0, "90th_percentile": 6764.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 4406.75, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4406.75, "10th_percentile": 4406.75, "90th_percentile": 4406.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 4406.75, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 4406.75, "10th_percentile": 4406.75, "90th_percentile": 4406.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Ingest Challenge Ini 120 Min", "code_information": [ { "code": "PX-92000017", "type": "CDM" }, { "code": "95076", "type": "CPT" }, { "code": "0920", "type": "RC" } ], "standard_charges": [ { "minimum": 223.25, "maximum": 1175.0, "setting": "outpatient", "gross_charge": 1175.0, "discounted_cash": 822.5, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 709.7, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 709.7, "10th_percentile": 709.7, "90th_percentile": 709.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 709.7, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 709.7, "10th_percentile": 709.7, "90th_percentile": 709.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 765.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 765.51, "10th_percentile": 765.51, "90th_percentile": 765.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 656.83, "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": 656.83, "10th_percentile": 656.83, "90th_percentile": 656.83, "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": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 740.25, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 740.25, "10th_percentile": 740.25, "90th_percentile": 740.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 959.98, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.98, "10th_percentile": 959.98, "90th_percentile": 959.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 223.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 223.25, "10th_percentile": 223.25, "90th_percentile": 223.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 223.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 223.25, "10th_percentile": 223.25, "90th_percentile": 223.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 223.25, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 223.25, "10th_percentile": 223.25, "90th_percentile": 223.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1175.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1175.0, "10th_percentile": 1175.0, "90th_percentile": 1175.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1175.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1175.0, "10th_percentile": 1175.0, "90th_percentile": 1175.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 768.45, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.45, "10th_percentile": 768.45, "90th_percentile": 768.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 298.45, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 298.45, "10th_percentile": 298.45, "90th_percentile": 298.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 814.28, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 814.28, "10th_percentile": 814.28, "90th_percentile": 814.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 408.9, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 408.9, "10th_percentile": 408.9, "90th_percentile": 408.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1175.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1175.0, "10th_percentile": 1175.0, "90th_percentile": 1175.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1028.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1028.13, "10th_percentile": 1028.13, "90th_percentile": 1028.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 765.51, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 765.51, "10th_percentile": 765.51, "90th_percentile": 765.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 638.61, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 638.61, "10th_percentile": 638.61, "90th_percentile": 638.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 791.95, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 791.95, "10th_percentile": 791.95, "90th_percentile": 791.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 881.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 881.25, "10th_percentile": 881.25, "90th_percentile": 881.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 998.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 998.75, "10th_percentile": 998.75, "90th_percentile": 998.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 528.75, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 528.75, "10th_percentile": 528.75, "90th_percentile": 528.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 940.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 940.0, "10th_percentile": 940.0, "90th_percentile": 940.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 959.98, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.98, "10th_percentile": 959.98, "90th_percentile": 959.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 589.85, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.85, "10th_percentile": 589.85, "90th_percentile": 589.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 786.08, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 786.08, "10th_percentile": 786.08, "90th_percentile": 786.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Other OP; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 567.53, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 567.53, "10th_percentile": 567.53, "90th_percentile": 567.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 532.28, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 532.28, "10th_percentile": 532.28, "90th_percentile": 532.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "HB Inject Spine Cerv/Thoracic", "code_information": [ { "code": "PX-36100699", "type": "CDM" }, { "code": "62320", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 1919.15, "maximum": 3823.0, "setting": "outpatient", "gross_charge": 3823.0, "discounted_cash": 2676.1, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3823.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3823.0, "10th_percentile": 3823.0, "90th_percentile": 3823.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1919.15, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1919.15, "10th_percentile": 1919.15, "90th_percentile": 1919.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2557.59, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2557.59, "10th_percentile": 2557.59, "90th_percentile": 2557.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Injection Aa&/Strd Ilioinguinal Ih Nerves", "code_information": [ { "code": "CASE-64425", "type": "LOCAL" }, { "code": "64425", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4773.24, "discounted_cash": 3341.27, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 3121.71, "10th_percentile": 3121.71, "90th_percentile": 3121.71, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 3307.86, "10th_percentile": 3307.86, "90th_percentile": 3307.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_percentage": 34.8, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 1661.08, "10th_percentile": 1661.08, "90th_percentile": 1661.08, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_percentage": 25.4, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 1212.41, "10th_percentile": 1212.41, "90th_percentile": 1212.41, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 906.94, "10th_percentile": 906.94, "90th_percentile": 906.94, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 3109.78, "10th_percentile": 3109.78, "90th_percentile": 3109.78, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 76.7, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 3661.08, "10th_percentile": 3661.08, "90th_percentile": 3661.08, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 906.94, "10th_percentile": 906.94, "90th_percentile": 906.94, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 57.7, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 2754.17, "10th_percentile": 2754.17, "90th_percentile": 2754.17, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 57.2, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 2730.3, "10th_percentile": 2730.3, "90th_percentile": 2730.3, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 57.7, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 2754.17, "10th_percentile": 2754.17, "90th_percentile": 2754.17, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS HMO", "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 3109.78, "10th_percentile": 3109.78, "90th_percentile": 3109.78, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 55.9, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 2668.25, "10th_percentile": 2668.25, "90th_percentile": 2668.25, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_percentage": 76.7, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 3661.08, "10th_percentile": 3661.08, "90th_percentile": 3661.08, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 329.36, "10th_percentile": 329.36, "90th_percentile": 329.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 3217.18, "10th_percentile": 3217.18, "90th_percentile": 3217.18, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 1886.42, "10th_percentile": 1886.42, "90th_percentile": 1886.42, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 2011.02, "10th_percentile": 2011.02, "90th_percentile": 2011.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTHSPRING SPECIALCARE OF IL [1608]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 329.36, "10th_percentile": 329.36, "90th_percentile": 329.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 329.36, "10th_percentile": 329.36, "90th_percentile": 329.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FAMILY HEALTH NETWORK HMO [1610]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 329.36, "10th_percentile": 329.36, "90th_percentile": 329.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 4773.25, "10th_percentile": 4773.25, "90th_percentile": 4773.25, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 906.94, "10th_percentile": 906.94, "90th_percentile": 906.94, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 329.36, "10th_percentile": 329.36, "90th_percentile": 329.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 4057.28, "10th_percentile": 4057.28, "90th_percentile": 4057.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_percentage": 45.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 2147.98, "10th_percentile": 2147.98, "90th_percentile": 2147.98, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 3579.96, "10th_percentile": 3579.96, "90th_percentile": 3579.96, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MERIDIAN HEALTH PLAN HMO [1604]", "plan_name": "VWH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 329.36, "10th_percentile": 329.36, "90th_percentile": 329.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_percentage": 87.5, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 4176.6, "10th_percentile": 4176.6, "90th_percentile": 4176.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 4773.25, "10th_percentile": 4773.25, "90th_percentile": 4773.25, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 4011.26, "10th_percentile": 4011.26, "90th_percentile": 4011.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 2594.26, "10th_percentile": 2594.26, "90th_percentile": 2594.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 2091.88, "10th_percentile": 2091.88, "90th_percentile": 2091.88, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 2785.44, "10th_percentile": 2785.44, "90th_percentile": 2785.44, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs and other services can be included in reimbursement.", "median_amount": 4773.25, "10th_percentile": 4773.25, "90th_percentile": 4773.25, "count": "1 through 10", "methodology": "percent of total billed charges" } ] } ] }, { "description": "HB Injection Aa&/Strd Sciatic Nerve W/Img Gdn", "code_information": [ { "code": "PX-76100032", "type": "CDM" }, { "code": "64445", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 558.6, "maximum": 2940.0, "setting": "outpatient", "gross_charge": 2940.0, "discounted_cash": 2058.0, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1852.2, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1852.2, "10th_percentile": 1852.2, "90th_percentile": 1852.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2401.98, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2401.98, "10th_percentile": 2401.98, "90th_percentile": 2401.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1775.76, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1775.76, "10th_percentile": 1775.76, "90th_percentile": 1775.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1775.76, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1775.76, "10th_percentile": 1775.76, "90th_percentile": 1775.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1643.46, "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": 1643.46, "10th_percentile": 1643.46, "90th_percentile": 1643.46, "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 2401.98, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2401.98, "10th_percentile": 2401.98, "90th_percentile": 2401.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1331.82, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1331.82, "10th_percentile": 1331.82, "90th_percentile": 1331.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1420.02, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1420.02, "10th_percentile": 1420.02, "90th_percentile": 1420.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 2499.0, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 2499.0, "10th_percentile": 2499.0, "90th_percentile": 2499.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2205.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2205.0, "10th_percentile": 2205.0, "90th_percentile": 2205.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 1597.89, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 1597.89, "10th_percentile": 1597.89, "90th_percentile": 1597.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1981.56, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1981.56, "10th_percentile": 1981.56, "90th_percentile": 1981.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 2572.5, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 2572.5, "10th_percentile": 2572.5, "90th_percentile": 2572.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 2352.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 2352.0, "10th_percentile": 2352.0, "90th_percentile": 2352.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1323.0, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1323.0, "10th_percentile": 1323.0, "90th_percentile": 1323.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 746.76, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 746.76, "10th_percentile": 746.76, "90th_percentile": 746.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1023.12, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1023.12, "10th_percentile": 1023.12, "90th_percentile": 1023.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2037.42, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2037.42, "10th_percentile": 2037.42, "90th_percentile": 2037.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1922.76, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1922.76, "10th_percentile": 1922.76, "90th_percentile": 1922.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 558.6, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 558.6, "10th_percentile": 558.6, "90th_percentile": 558.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 558.6, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 558.6, "10th_percentile": 558.6, "90th_percentile": 558.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 558.6, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 558.6, "10th_percentile": 558.6, "90th_percentile": 558.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2940.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2940.0, "10th_percentile": 2940.0, "90th_percentile": 2940.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2940.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2940.0, "10th_percentile": 2940.0, "90th_percentile": 2940.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 1915.41, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1915.41, "10th_percentile": 1915.41, "90th_percentile": 1915.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1915.41, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1915.41, "10th_percentile": 1915.41, "90th_percentile": 1915.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Injection Inclu Needle/Cath Plct Interlaminar Lmbr/Sac", "code_information": [ { "code": "PX-36100880", "type": "CDM" }, { "code": "62322", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 2099.36, "maximum": 4182.0, "setting": "outpatient", "gross_charge": 4182.0, "discounted_cash": 2927.4, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4182.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4182.0, "10th_percentile": 4182.0, "90th_percentile": 4182.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2099.36, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2099.36, "10th_percentile": 2099.36, "90th_percentile": 2099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2797.76, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2797.76, "10th_percentile": 2797.76, "90th_percentile": 2797.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Injection Single/Mlt Trigger Point 1/2 Muscles", "code_information": [ { "code": "PX-36100184", "type": "CDM" }, { "code": "20552", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 133.76, "maximum": 704.0, "setting": "outpatient", "gross_charge": 704.0, "discounted_cash": 492.8, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 443.52, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 443.52, "10th_percentile": 443.52, "90th_percentile": 443.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 575.17, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 575.17, "10th_percentile": 575.17, "90th_percentile": 575.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 425.22, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 425.22, "10th_percentile": 425.22, "90th_percentile": 425.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 425.22, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 425.22, "10th_percentile": 425.22, "90th_percentile": 425.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 393.54, "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": 393.54, "10th_percentile": 393.54, "90th_percentile": 393.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 55.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 575.17, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 575.17, "10th_percentile": 575.17, "90th_percentile": 575.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 318.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 318.91, "10th_percentile": 318.91, "90th_percentile": 318.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 340.03, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 340.03, "10th_percentile": 340.03, "90th_percentile": 340.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 598.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 598.4, "10th_percentile": 598.4, "90th_percentile": 598.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 528.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 528.0, "10th_percentile": 528.0, "90th_percentile": 528.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 382.62, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 382.62, "10th_percentile": 382.62, "90th_percentile": 382.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 474.5, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 474.5, "10th_percentile": 474.5, "90th_percentile": 474.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 616.0, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 616.0, "10th_percentile": 616.0, "90th_percentile": 616.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 563.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 563.2, "10th_percentile": 563.2, "90th_percentile": 563.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 316.8, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 316.8, "10th_percentile": 316.8, "90th_percentile": 316.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 178.82, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 194.3, "10th_percentile": 194.3, "90th_percentile": 194.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 244.99, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 244.99, "10th_percentile": 244.99, "90th_percentile": 244.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 487.87, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 487.87, "10th_percentile": 487.87, "90th_percentile": 487.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 460.42, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 460.42, "10th_percentile": 460.42, "90th_percentile": 460.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 133.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 133.76, "10th_percentile": 133.76, "90th_percentile": 133.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 133.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 133.76, "10th_percentile": 133.76, "90th_percentile": 133.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 133.76, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 133.76, "10th_percentile": 133.76, "90th_percentile": 133.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 704.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 704.0, "10th_percentile": 704.0, "90th_percentile": 704.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 704.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 704.0, "10th_percentile": 704.0, "90th_percentile": 704.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 458.66, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 458.66, "10th_percentile": 458.66, "90th_percentile": 458.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 458.66, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 458.66, "10th_percentile": 458.66, "90th_percentile": 458.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Ins Mark Thor for Rt Perq", "code_information": [ { "code": "PX-36100377", "type": "CDM" }, { "code": "32553", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 339.53, "maximum": 1787.0, "setting": "outpatient", "gross_charge": 1787.0, "discounted_cash": 1250.9, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1125.81, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1125.81, "10th_percentile": 1125.81, "90th_percentile": 1125.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1459.98, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1459.98, "10th_percentile": 1459.98, "90th_percentile": 1459.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1079.35, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1079.35, "10th_percentile": 1079.35, "90th_percentile": 1079.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1079.35, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1079.35, "10th_percentile": 1079.35, "90th_percentile": 1079.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 998.93, "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": 998.93, "10th_percentile": 998.93, "90th_percentile": 998.93, "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1459.98, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1459.98, "10th_percentile": 1459.98, "90th_percentile": 1459.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 809.51, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 809.51, "10th_percentile": 809.51, "90th_percentile": 809.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 863.12, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 863.12, "10th_percentile": 863.12, "90th_percentile": 863.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 1518.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1518.95, "10th_percentile": 1518.95, "90th_percentile": 1518.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1340.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1340.25, "10th_percentile": 1340.25, "90th_percentile": 1340.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 971.23, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 971.23, "10th_percentile": 971.23, "90th_percentile": 971.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1204.44, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1204.44, "10th_percentile": 1204.44, "90th_percentile": 1204.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1563.63, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1563.63, "10th_percentile": 1563.63, "90th_percentile": 1563.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1429.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1429.6, "10th_percentile": 1429.6, "90th_percentile": 1429.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 804.15, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 804.15, "10th_percentile": 804.15, "90th_percentile": 804.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 453.9, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 453.9, "10th_percentile": 453.9, "90th_percentile": 453.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 621.88, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 621.88, "10th_percentile": 621.88, "90th_percentile": 621.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1238.39, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1238.39, "10th_percentile": 1238.39, "90th_percentile": 1238.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1168.7, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1168.7, "10th_percentile": 1168.7, "90th_percentile": 1168.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 339.53, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 339.53, "10th_percentile": 339.53, "90th_percentile": 339.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 339.53, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 339.53, "10th_percentile": 339.53, "90th_percentile": 339.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 339.53, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 339.53, "10th_percentile": 339.53, "90th_percentile": 339.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1787.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1787.0, "10th_percentile": 1787.0, "90th_percentile": 1787.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1787.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1787.0, "10th_percentile": 1787.0, "90th_percentile": 1787.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 1164.23, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1164.23, "10th_percentile": 1164.23, "90th_percentile": 1164.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1164.23, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1164.23, "10th_percentile": 1164.23, "90th_percentile": 1164.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Ins Tun IP Cath for Dial Opn", "code_information": [ { "code": "PX-36100584", "type": "CDM" }, { "code": "49421", "type": "CPT" }, { "code": "0361", "type": "RC" } ], "standard_charges": [ { "minimum": 2579.78, "maximum": 5139.0, "setting": "outpatient", "gross_charge": 5139.0, "discounted_cash": 3597.3, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5139.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5139.0, "10th_percentile": 5139.0, "90th_percentile": 5139.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 2579.78, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2579.78, "10th_percentile": 2579.78, "90th_percentile": 2579.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 3437.99, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3437.99, "10th_percentile": 3437.99, "90th_percentile": 3437.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "HB Insert Cecostomy/Other Colonic Tube Percutaneous", "code_information": [ { "code": "PX-75000417", "type": "CDM" }, { "code": "49442", "type": "CPT" }, { "code": "0750", "type": "RC" } ], "standard_charges": [ { "minimum": 700.53, "maximum": 3687.0, "setting": "outpatient", "gross_charge": 3687.0, "discounted_cash": 2580.9, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 700.53, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 700.53, "10th_percentile": 700.53, "90th_percentile": 700.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 700.53, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 700.53, "10th_percentile": 700.53, "90th_percentile": 700.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 700.53, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "No historical claim; Outpatient Services; 19% Billed", "median_amount": 700.53, "10th_percentile": 700.53, "90th_percentile": 700.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Outpatient Services; 19% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 1670.21, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1670.21, "10th_percentile": 1670.21, "90th_percentile": 1670.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 1780.82, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1780.82, "10th_percentile": 1780.82, "90th_percentile": 1780.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 2402.08, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2402.08, "10th_percentile": 2402.08, "90th_percentile": 2402.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 2765.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 2765.25, "10th_percentile": 2765.25, "90th_percentile": 2765.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 2485.04, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 2485.04, "10th_percentile": 2485.04, "90th_percentile": 2485.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 3226.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 3226.13, "10th_percentile": 3226.13, "90th_percentile": 3226.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 2003.88, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 2003.88, "10th_percentile": 2003.88, "90th_percentile": 2003.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 1659.15, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 1659.15, "10th_percentile": 1659.15, "90th_percentile": 1659.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN", "standard_charge_dollar": 3133.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 3133.95, "10th_percentile": 3133.95, "90th_percentile": 3133.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 3133.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OP Surgical Svcs; 85% Billed", "median_amount": 3133.95, "10th_percentile": 3133.95, "90th_percentile": 3133.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgical Svcs; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3687.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3687.0, "10th_percentile": 3687.0, "90th_percentile": 3687.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC CORE", "standard_charge_dollar": 1850.87, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1850.87, "10th_percentile": 1850.87, "90th_percentile": 1850.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "VWH UHC HMO/PPO", "standard_charge_dollar": 2466.6, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2466.6, "10th_percentile": 2466.6, "90th_percentile": 2466.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Surgery; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 2555.09, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2555.09, "10th_percentile": 2555.09, "90th_percentile": 2555.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 2411.3, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2411.3, "10th_percentile": 2411.3, "90th_percentile": 2411.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Amb Surgery; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 1283.08, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 1283.08, "10th_percentile": 1283.08, "90th_percentile": 1283.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 936.5, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 936.5, "10th_percentile": 936.5, "90th_percentile": 936.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3687.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3687.0, "10th_percentile": 3687.0, "90th_percentile": 3687.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3687.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3687.0, "10th_percentile": 3687.0, "90th_percentile": 3687.0, "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": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2061.03, "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": 2061.03, "10th_percentile": 2061.03, "90th_percentile": 2061.03, "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": "VWH BCBS HMO", "standard_charge_dollar": 2402.08, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 2402.08, "10th_percentile": 2402.08, "90th_percentile": 2402.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Insert Tun IP Cath W/Port", "code_information": [ { "code": "PX-36100583", "type": "CDM" }, { "code": "49419", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 1107.7, "maximum": 5830.0, "setting": "outpatient", "gross_charge": 5830.0, "discounted_cash": 4081.0, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3672.9, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3672.9, "10th_percentile": 3672.9, "90th_percentile": 3672.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4763.11, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4763.11, "10th_percentile": 4763.11, "90th_percentile": 4763.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3521.32, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3521.32, "10th_percentile": 3521.32, "90th_percentile": 3521.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3521.32, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3521.32, "10th_percentile": 3521.32, "90th_percentile": 3521.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3258.97, "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": 3258.97, "10th_percentile": 3258.97, "90th_percentile": 3258.97, "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 4763.11, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4763.11, "10th_percentile": 4763.11, "90th_percentile": 4763.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 2640.99, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2640.99, "10th_percentile": 2640.99, "90th_percentile": 2640.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 2815.89, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2815.89, "10th_percentile": 2815.89, "90th_percentile": 2815.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 4955.5, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 4955.5, "10th_percentile": 4955.5, "90th_percentile": 4955.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 4372.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 4372.5, "10th_percentile": 4372.5, "90th_percentile": 4372.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 3168.61, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 3168.61, "10th_percentile": 3168.61, "90th_percentile": 3168.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 3929.42, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 3929.42, "10th_percentile": 3929.42, "90th_percentile": 3929.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 5101.25, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 5101.25, "10th_percentile": 5101.25, "90th_percentile": 5101.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 4664.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 4664.0, "10th_percentile": 4664.0, "90th_percentile": 4664.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 2623.5, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 2623.5, "10th_percentile": 2623.5, "90th_percentile": 2623.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 1480.82, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 1480.82, "10th_percentile": 1480.82, "90th_percentile": 1480.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 2028.84, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 2028.84, "10th_percentile": 2028.84, "90th_percentile": 2028.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 4040.19, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4040.19, "10th_percentile": 4040.19, "90th_percentile": 4040.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 3812.82, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3812.82, "10th_percentile": 3812.82, "90th_percentile": 3812.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 1107.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1107.7, "10th_percentile": 1107.7, "90th_percentile": 1107.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 1107.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1107.7, "10th_percentile": 1107.7, "90th_percentile": 1107.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 1107.7, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 1107.7, "10th_percentile": 1107.7, "90th_percentile": 1107.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5830.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5830.0, "10th_percentile": 5830.0, "90th_percentile": 5830.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5830.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5830.0, "10th_percentile": 5830.0, "90th_percentile": 5830.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 3798.25, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3798.25, "10th_percentile": 3798.25, "90th_percentile": 3798.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 3798.25, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 3798.25, "10th_percentile": 3798.25, "90th_percentile": 3798.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Insertion of Chest Tube", "code_information": [ { "code": "PX-36100375", "type": "CDM" }, { "code": "32551", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 334.21, "maximum": 1759.0, "setting": "outpatient", "gross_charge": 1759.0, "discounted_cash": 1231.3, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1108.17, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1108.17, "10th_percentile": 1108.17, "90th_percentile": 1108.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 63% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1437.1, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1437.1, "10th_percentile": 1437.1, "90th_percentile": 1437.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1062.44, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1062.44, "10th_percentile": 1062.44, "90th_percentile": 1062.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1062.44, "standard_charge_percentage": 60.4, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1062.44, "10th_percentile": 1062.44, "90th_percentile": 1062.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 60.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 983.28, "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": 983.28, "10th_percentile": 983.28, "90th_percentile": 983.28, "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS PPO", "standard_charge_dollar": 1437.1, "standard_charge_percentage": 81.7, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1437.1, "10th_percentile": 1437.1, "90th_percentile": 1437.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 81.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA ALTERNATIVE", "standard_charge_dollar": 796.83, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 796.83, "10th_percentile": 796.83, "90th_percentile": 796.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "VWH CIGNA BROAD", "standard_charge_dollar": 849.6, "standard_charge_percentage": 48.3, "standard_charge_algorithm": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 849.6, "10th_percentile": 849.6, "90th_percentile": 849.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Ambulatory Surgery; 48.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "VWH HFN", "standard_charge_dollar": 1495.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "All Services; 85% Billed", "median_amount": 1495.15, "10th_percentile": 1495.15, "90th_percentile": 1495.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "VWH SEIU HEALTHLINK", "standard_charge_dollar": 1319.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Outpatient Services; 75% Billed", "median_amount": 1319.25, "10th_percentile": 1319.25, "90th_percentile": 1319.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "VWH THE ALLIANCE", "standard_charge_dollar": 956.02, "standard_charge_percentage": 54.35, "standard_charge_algorithm": "Outpatient Services; 54.35% Billed", "median_amount": 956.02, "10th_percentile": 956.02, "90th_percentile": 956.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 54.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "VWH CHOICE CARE", "standard_charge_dollar": 1185.57, "standard_charge_percentage": 67.4, "standard_charge_algorithm": "Outpatient; 67.4% Billed", "median_amount": 1185.57, "10th_percentile": 1185.57, "90th_percentile": 1185.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 67.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH MULTIPLAN", "standard_charge_dollar": 1539.13, "standard_charge_percentage": 87.5, "standard_charge_algorithm": "All Services; 87.5% Billed", "median_amount": 1539.13, "10th_percentile": 1539.13, "90th_percentile": 1539.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH PHCS", "standard_charge_dollar": 1407.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "All Other OP Services; 80% Billed", "median_amount": 1407.2, "10th_percentile": 1407.2, "90th_percentile": 1407.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "VWH HFN NMH TIER ONE", "standard_charge_dollar": 791.55, "standard_charge_percentage": 45.0, "standard_charge_algorithm": "ALL OTH SRVS; 45% Billed", "median_amount": 791.55, "10th_percentile": 791.55, "90th_percentile": 791.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SRVS; 45% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA NM EMPLOYEES", "standard_charge_dollar": 446.79, "standard_charge_percentage": 25.4, "standard_charge_algorithm": "All Services; 25.4% Billed", "median_amount": 446.79, "10th_percentile": 446.79, "90th_percentile": 446.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 25.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA IL PREFERRED", "standard_charge_dollar": 612.13, "standard_charge_percentage": 34.8, "standard_charge_algorithm": "All Outpatient Services; 34.8% Billed", "median_amount": 612.13, "10th_percentile": 612.13, "90th_percentile": 612.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 34.8% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA ASA", "standard_charge_dollar": 1218.99, "standard_charge_percentage": 69.3, "standard_charge_algorithm": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1218.99, "10th_percentile": 1218.99, "90th_percentile": 1218.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 69.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "VWH AETNA", "standard_charge_dollar": 1150.39, "standard_charge_percentage": 65.4, "standard_charge_algorithm": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1150.39, "10th_percentile": 1150.39, "90th_percentile": 1150.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient Services; 65.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "VWH MEDICARE", "standard_charge_dollar": 334.21, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 334.21, "10th_percentile": 334.21, "90th_percentile": 334.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "VWH MEDICARE", "standard_charge_dollar": 334.21, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 334.21, "10th_percentile": 334.21, "90th_percentile": 334.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "VWH BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 334.21, "standard_charge_percentage": 19.0, "standard_charge_algorithm": "Outpatient Services; 19% Billed", "median_amount": 334.21, "10th_percentile": 334.21, "90th_percentile": 334.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 19% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1759.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1759.0, "10th_percentile": 1759.0, "90th_percentile": 1759.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "VWH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1759.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1759.0, "10th_percentile": 1759.0, "90th_percentile": 1759.0, "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": "VWH BCBS HMO", "standard_charge_dollar": 1145.99, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1145.99, "10th_percentile": 1145.99, "90th_percentile": 1145.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "VWH BCBS HMO", "standard_charge_dollar": 1145.99, "standard_charge_percentage": 65.15, "standard_charge_algorithm": "Outpatient; 65.15% Billed", "median_amount": 1145.99, "10th_percentile": 1145.99, "90th_percentile": 1145.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 65.15% Billed" } ] } ] }, { "description": "HB Insj Subq Impltbl Dfb Elctrd", "code_information": [ { "code": "PX-36100389", "type": "CDM" }, { "code": "33271", "type": "CPT" }, { "code": "0761", "type": "RC" } ], "standard_charges": [ { "minimum": 4999.28, "maximum": 26312.0, "setting": "outpatient", "gross_charge": 26312.0, "discounted_cash": 18418.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "VWH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 14708.41, "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": 14708.41,